summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Based on records review and interviews with staff and clients that show the facility has been utilizing a 1:6 staff-to-child ratio instead of the 1:3 ratio noted in the Licensee's Plan of Operation, and reports that there was at least one incident when clients were left without staff at the facility for at least 30 minutes during a staff medical emergency, the allegation "Facility does not have adequate staffing" is found to be substantiated. A deficiency was cited per Title Regulations, Division 6, Chapter 1, Article 3, Section 80022(k) - Plan of Operation. Please see attached LIC9099-D for details. At this time, one deficiency was cited. An exit interview was conducted with Ms. Hooper, who signed this report. Appeal Rights provided and discussed, and a copy of this report was emailed to Administrator, Devorah Weiss at 12: PM.

Investigation Findings:
13At 10: AM, Licensing Program Analyst (LPA) Singh-Sood traveled to the home above for the purpose of conducting an unannounced complaint investigation inspection. LPA met with __ in person and Devorah Weiss by telephone, who helped facilitate this inspection. Currently in care are 2 ambulatory clients. On 02/08/2023, the San Jose Children's Residential Program Regional Office received a complaint for Evolve Treatment Centers Walnut Creek with one allegation: "Minors are left without supervision." This complaint was assigned to and investigated by LPA Fremont. Based on records review and interviews with staff and clients that show the facility has been utilizing a 1:6 staff-to-child ratio instead of the 1:3 ratio noted in the Licensee"s Plan of Operation, and reports that there was at least one incident when clients were left without staff at the facility for at least 30 minutes during a staff medical emergency, the allegation "Facility does not have adequate staffing" is found to be substantiated. A deficiency was cited per Title Regulations, Division 6, Chapter 1, Article 3, Section 80022(k) - Plan of Operation. Please see attached LIC9099-D for details. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Vaishali Singh-Sood LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: EVOLVE TREATMENT CENTER, DANVILLEFACILITY NUMBER: VISIT DATE: 07/19/2023

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

met_with: Chunna Hooper


state: CA

facility_name: EVOLVE TREATMENT CENTER, DANVILLE

summary: Complaint Investigation - Substantiated - 1 deficiency - 1 allegation

raw_content:
Investigation Findings:
13On 7/17/2025 at 2: PM, Licensing Program Analyst (LPA) Jonathan Medina conducted a complaint investigation visit to deliver findings. LPA met with facility nurse Chynna Hooper and explained the purpose of the visit. The Administrator was unavailable; however, the facility nurse was authorized to sign the report. Based on confidential interviews, incident reports, and record reviews, the allegation that the licensee failed to maintain sufficient staff to ensure adequate supervision of minors is SUBSTANTIATED. This violates Title 22, Section 80078(a) - Responsibility for Providing Care and Supervision. Please refer to LIC 809-D for additional details. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to facility nurse Chynna Hooper, whose signature below confirms receipt. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Jonathan Medina LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE FACILITY NAME: EVOLVE TREATMENT CENTER, DANVILLEFACILITY NUMBER: 075650151

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

Deficiencies:
84065.5(c): (c) If the children require special care and supervision because of age, problem behavior or other factors, the number of on-duty child care staff shall be increased.

report_type: Complaint Investigation

met_with: Facility nurse, Chynna Hooper

complaint_status: SUBSTANTIATED

title: Staff/Child Ratios


summary: Facility Evaluation

raw_content:
Narrative:
At 10:15AM, Licensing Program Analyst (LPA) Madeleine Fremont initiated an unannounced Required Annual Inspection with Evolve Treatment Center, Danville. LPA Fremont met with Compliance Officer Devorah Weiss, who helped facilitate this inspection. Currently in care are 4 ambulatory clients. One additional client was being admitted at the end of the day. Due to unsafe weather and avoiding interrupting Christmas activities for the clients, LPA Fremont informed the licensee that the inspection of the home's physical plant would take place on a later date. LPA requested the following records to be provided over email for the staff and client records review portion of the inspection: 10 staff records and all client records. Inspection was paused and will be completed after the Christmas Holiday. _________________________________________________________________________ On 12/27/2021 at 12:55AM, LPA Fremont traveled to Evolve Treatment Center, Danville to complete the home's required annual inspection. LPA met with Facility Manager Stacy Guerrero, who helped facilitate this inspection. Currently in care are 4 ambulatory clients. During this inspection, LPA Fremont toured the facility inside and out. The home is a split level home located in Danville, CA. The home had 4 client bedrooms (2 double occupancy; 2 single occupancy), which were all observed with comfortable furnishings and lighting. Each room had more than the required closet/shelf space to store their personal belongings and clothing. The facility contains 4 bathrooms, one of which is located in the staff offices downstairs and is not accessible to clients. (Continued on Lic809-c) During this visit, LPA Fremont inspected 10 staff files and 4 client files. All client files were complete with all required documentation. The following staff files were missing the items listed below (see LIC811 - Confidential Names dated 12/27/2021): - S2 - missing TB test - S6 - missing LIC Health Screening and TB test - S7 - missing LIC Personnel Record - S8 - missing LIC Personnel Record, LIC Health Screening, TB test - S9 - missing LIC Health Screening - S10 - missing LIC Health Screening Regarding these missing documents, the licensee was issued two LIC Advisory Notes: 1. For missing documents such as LIC501 and LIC503, the licensee was issued an Advisory Note - Technical Advisory for Title 22, Division 6, Chapter 1, Article 6, Section 80066(a)(10) - Personnel Records (please reference LIC9102 - Advisory Note dated 12/24/2021). 2. For missing tuberculosis tests, the licensee was issued an Advisory Note - Technical Advisory for Title 22, Division 6, Chapter 1, Article 6, Section 80066(a)(11) - Personnel Records (please reference LIC9102 - Advisory Note dated 12/24/2021). At this time, no deficiencies were cited. Two Advisory Notes were issued to the licensee. An exit interview was conducted, Appeal Rights provided and discussed and a copy of this report was emailed to the licensee, whose signature confirms receipt. The home has a living room, kitchen, dining room, group therapy room, and study/school room, all of which are comfortably furnished with adequate lighting. The home has 4 staff offices. There is one fireplace located in the school room, which is inoperable (gas disconnected). There are 41 cameras in total on the property - 23 inside in common areas and 18 on the exterior of the home. All camera views have been submitted to and approved by Community Care Licensing to ensure no camera points into a bedroom or bathroom window. LPA Fremont observed the home to be clean, safe, and sanitary. All walkways are unobstructed and free of debris. The thermostat was set to 71 degrees. In the kitchen, LPA observed at least 2 days of perishable food and 7 days of nonperishable food. There is also a variety of snacks available to clients upon request. An emergency food supply is kept in the kitchen. The refrigerator and freezer were set to the proper temperatures, and there is a temperature log on each that staff sign off daily to ensure the proper temperature is maintained. Toxins and sharps are properly stored and inaccessible to clients. There are smoke detectors located in all rooms and walkways, and all are operable and linked together (one alarm going off will trigger all others). Carbon monoxide detectors are located throughout the home and are operable. Fire extinguishers are located in the kitchen, garage, hallway, facility manager's office, and all have been inspected and approved by the fire department. The pool is surrounded on all sides by a fence, which has a self-latching closure. Medication is stored in locked cabinets in the nurses' station. The Centrally Stored Medication Log and Medication Administration Records were both observed to be in locked cabinets in the nurse's station. 3 first aid kits are located throughout the facility in the nurse's station, kitchen, and emergency bag. All faucets which are accessible to clients were observed to be between 108-111 degrees Fahrenheit. The gas shutoff is located in the backyard, and the water shutoff was located in the front of the house. (Continued on Lic809-c)

report_type: Facility Evaluation

visit_type: Annual

met_with: Compliance Officer Devorah Weiss


summary: Facility Evaluation

raw_content:
Narrative:
On 12-12-23 10:09, Licensing Program Analysts George Karkazis conducted an unannounced Annual/Random inspection at listed facility. LPA met with Niekachi Nwogu, Clinical Program Director and toured the facility inside and out. The Group Home is licensed to serve 6 clients. Present during the inspection were 6 staff and 3 clients. At 10:15AM LPA Karkazis reviewed client and staff files. All staff and client files are complete and in good order. At 1:00PM, LPA Karkazis toured the facility. LPA Karkazis observed 4 bedrooms and 4 bathrooms. LPA observed facility license, personal rights, facility sketch, meal menu, and other forms posted on the walls throughout the facility. LPA Karkazis tested the water temperature and found it to be 117 degrees which is in range. The thermostat read 68 degrees which is within range. Sharps were locked and chemicals were safely stored. There were two days of perishable foods and seven days non-perishable foods present. The medication was stored and locked in the nurse's office in a locked safe. The facility is in good repair and clean. LPA Karkazis interviewed 4 staff and 2 clients. At 1:20PM LPA Karkazis toured the backyard. There were no open bodies of water. The backyard was in good repair and clean. At this time there were no deficiencies. An exit interview was conducted, appeal rights discussed and a copy of this report was given to Niekachi Nwogu, Clinical Program Director.


summary: Facility Evaluation

raw_content:
Narrative:
On November 5th, 2025 at 10:35AM, Licensing Program Analyst (LPA) Hanako Primer conducted an unannounced Annual Inspection at the listed facility. LPA met with Sherice Youngblood, Program Director, Devorah Weiss, Compliance Officer, and Dina Letitchevski, Senior People Operations Generalist. LPA toured the facility inside and out. The Group Home is licensed to serve six clients. Present during the inspection were six clients. LPA reviewed five staff files. LPA inspected CPR and first aid certificates, health screening, onboarding training, TB tests, job descriptions, and CPI training in five out of five staff files. LPA Primer toured the facility. LPA observed four bedrooms and four bathrooms. LPA observed facility license, facility sketch, meal menu, and other forms posted on the walls throughout the facility. LPA tested the water temperature and found it to be 122 degrees. LPA issued one technical violation under California Code of Regulations (CCR) 80088(e)(1) Fixtures, Furniture, Equipment, and Supplies. See attached LIC9102. Sharps were locked and chemicals were safely stored. There were two days of perishable foods and seven days non-perishable foods present. The medication was also stored and locked in nurse's station. The facility is in good repair and clean. LPA toured the backyard. There were no open bodies of water. The backyard was in good repair and clean. LPA interviewed two staff and two clients. At this time there were no deficiencies. An exit interview was conducted and a copy of this report was given to Sherice Youngblood, Program Director.

met_with: Sherice Youngblood - Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On 10/15/2025, Licensing Program Analyst (LPA) Jonathan Medina conducted a case management inspection to correct a licensing document dated 7/17/2025 for complaint 14-CR-20250512102801. LPA met with Facility nurse, Chynna Hooper. LPA disclosed the purpose of the inspection and was granted entry into the facility. At 2:00 p.m., LPA updated the LIC 9099 for complaint 14-CR-20250512102801 to reflect that only one deficiency was cited under California Code of Regulations (CCR), Title 22, Section 80078(a) - Responsibility for Providing Care and Supervision. The appeals process placed a hold on the Plan of Correction (POC) due date. The deficiency was re-assessed during today's visit, and a new due date was established. Now that the appeal process has concluded, the POC for the above-referenced complaint is outstanding and must be submitted by 10/31/2025. Please refer to LIC809-D for additional details. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Facility nurse, Chynna Hooper, whose signature below confirms receipt.


facility_name: EVOLVE TREATMENT CENTER, GILROY

summary: Facility Evaluation

raw_content:
Narrative:
At 2PM, Licensing Program Analyst (LPA) Madi Fremont traveled to Evolve Gilroy to conduct an unannounced Case Management Inspection. LPA did not meet with any staff or other representative of the program. On September 30, 2021, the San Jose Children's Residential Program Regional Office received a letter from Evolve's Compliance Officer, Devorah Weiss. In this letter, Ms. Weiss reported that due to ongoing struggles brought about by the COVID-19 pandemic, the home located at Butch Drive in Gilroy, CA would be surrendering it's license and closing permanently. The purpose of LPA Fremont's unannounced Case Management Inspection on 10/26/2021 was to confirm that no clients or staff were present on the grounds before the facility is closed permanently in Community Care Licensing's Licensing Information System. LPA walked the grounds of the facility located at Butch Drive, and did not see any staff or clients present. There were no cars in the driveway, all windows and doors were shut, and there were no lights on in any of the buildings on the property. LPA Fremont confirmed with Licensing Program Managers Helga Wong and Carolyn Flynn that no clients are currently placed at Evolve Gilory, and the facility appears to be closed permanently. No deficiencies observed or cited. This document will not be signed by a facility representative as none were present on the property at the time of this inspection.

visit_type: Case Management

met_with: No one present on facility grounds


facility_name: EVOLVE TREATMENT CENTER, LAFAYETTE

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Minors are not treated with dignity Confidential interviews revealed conflicting statements that clients must leave the bathroom door ajar while using the restroom. Some confidential interviews reported that the clients did not have to leave the door open while using the restroom and other interviews stated that clients must leave the bathroom door ajar while using the restroom. It was noted in the facility's program statement that staff are to ensure that the clients keep the bathroom door ajar when using the restroom. Minors are not allowed hygiene items Confidential interviews revealed conflicting statements regarding whether clients are not allowed hygiene items. Interview information revealed that clients are given hygiene boxes that contain toothbrush, toothpaste, soap, shampoo, conditioner, deodorant, lotion, and other products which are available when the clients request them. Confidential interviews stated that clients are provided razors to shave but under the supervision of staff. It was noted in the facility's program statement that staff can withhold hygiene items from clients and provide them upon the request of the client depending on the client's level. Staff open minors' personal mail Confidential interviews indicated that the therapist keep all mail, unopened until the clients' next one-on-one therapy sessions. It was also disclosed that clients are required to open their letters in front of staff to make sure there is no contraband and confirmed that staff do not open clients' mails. Other confidential witnesses were unaware of the mail process and could not speak to this allegation. Some confidential witnesses stated that the clients open their personal mail in front of staff, and others stated the clients' primary therapists open their mail for them to screen letters and packages for contraband or triggering content. Minors not receiving an allowance Confidential interviews revealed that none of the minors received allowance during their residency at this Group Home. Per Facility Representative(s), the purpose of not providing clients allowance was to reduce the ability of incoming contraband. Facility Representative(s) also indicated that clients did not have a need for allowance as the Program provide the necessities for clients. Confidential interviews revealed that although allowance is not given, the facility provide for clients' needs which includes items while on outings. Minors are denied access to personal property Confidential interviews revealed that clients are denied personal property based on scheduled activities and for their safety. Some personal items are stored locked in a cabinet and made available to clients upon request. Per Facility Representative(s) some items such as razors require direct supervision, while other personal items (such as books, clothing and etc.) are not allowed to be possessed by clients because the item could trigger client's behaviors or jeopardize their safety while in treatment Based on the confidential interviews, observation, and record review, it has been determined that although the allegations that minors are not treated with dignity; minors are not allowed hygiene items; staff open minors' personal mail, minors not receiving an allowance, and minors being denied access to personal belongings may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. The program statement has been updated to ensure that the clients' needs will be met based on their individual assessments per Title Group Home Regulations. An exit interview was conducted, appeal rights discussed, and a copy of this report was provided to Brandi Ellis.

Investigation Findings:
13On 10:25AM, Licensing Program Analyst (LPA) Madeleine Fremont arrived at the facility to deliver the findings of a complaint investigation. LPA Fremont met with Administrator Brandi Ellis and discussed the investigative findings. On June 7, 2021, the Department received a complaint alleging minors are not treated with dignity; minors are not allowed hygiene items; staff open minors' personal mail; minors are not receiving an allowance; minors are being denied access to personal property. Confidential interviews were conducted with 4 staff and 2 clients. Facility's Program Statement, Plan of Operation, Parent Handbook and Training Manual were reviewed. The following information was obtained during the course of the investigation: (CONTINUED ON LIC9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Madeleine Fremont LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: EVOLVE TREATMENT CENTER, LAFAYETTEFACILITY NUMBER: VISIT DATE: 12/02/2021

met_with: Brandi Ellis

complaint_status: unsubstantiated


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Investigation Findings:
13At 11:15am on 5/19/2023, Licensing Program Analyst (LPA) Karmen Balhotra made an unannounced complaint inspection to the facility listed above. The reason for the inspection is to deliver findings for the allegation listed above. LPA met with Dawniel Page, Regional Clinical Director - who helped facilitate the inspection. Over the course of the investigation, LPA conducted confidential interviews and a file review. Evidence obtained revealed that for the allegations of; minor broke their truth while in care is found to be unsubstantiated. This agency has investigated the complaint alleging the allegations listed above and have found that the complaint is unsubstantiated, meaning that although the allegation may have happened, or is valid, there is not a preponderance of the evidence to prove that the allegations above occurred. Based on today's inspection,no California Code of Regulations were cited. An exit interview was conducted, and a copy of this report was left with Regional Clinical Director. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Karmen Balhotra LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Dawniel Page


raw_content:
Narrative:
Based on confidential interviews and record review, the staff was outside the opened door and the night shift resumed their 15-minute checks starting at 10PM. Based on record review, the facility protocol is to observe by listening during hygiene time and ensure that youth keep their doors open. The allegation that staff did not provide supervision when clients have inappropriate sexual behaviors in the facility has not met the preponderance of doubt and is therefore unsubstantiated. LPA conducted an exit interview with Savannah Sullivan, Operations Manager at 11:35AM whose signature confirms the receipt of the document.

Investigation Findings:
13On 8/4/2023 at 11:15AM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the licensed facility. The purpose of the visit was to deliver the finding for the above allegation. LPA met with Savannah Sullivan, Operations Manager. During the course of the investigation, LPA conducted twelve confidential interviews. LPA reviewed C1 and C2's treatment plans, shift notes for 7/21/2023-7/22/2023, incident reports, and facility's program statement. Based on confidential interviews, C1 and C2 did engage in sexual behaviors in the facility. Based on confidential interviews, three of the four interviewed remembered the door being open at the time. The same three interviewees had stated that the interaction happened in about 15-minutes. Based on confidential interviews, the sexual behavior happened during "hygiene" time between 9-10PM before the 15-minute checks are conducted between 10PM-6AM. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Selena Hood LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: EVOLVE TREATMENT CENTER, LAFAYETTEFACILITY NUMBER: VISIT DATE: 08/03/2023

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

met_with: Savannah Sullivan


raw_content:
Narrative:
Based on confidential interviews and record review, the staff was outside the opened door at the time of the incident and the night shift resumed their 15-minute checks starting at 10PM. Based on record review, the facility protocol is to observe by listening during hygiene time and ensure that youth keep their doors open. According to confidential interviews, immediately after being aware of the allegations, the facility staff had separated the two clients involved, conducted support sessions for the clients, and moved one client to another home. The facility had also updated their facility protocol to include visual check-ins during hygiene time. The allegation that staff did not provide supervision when clients have inappropriate sexual behaviors in the facility has met the preponderance of doubt and is therefore substantiated. Based on the staff members following their protocol, and the actions taken by the facility after the incident occurred, LPA did not provide the facility with a citation. LPA conducted an exit interview with Elijah Aquilina, Residential Counselor at 11:50AM whose signature confirms the receipt of the document.

Investigation Findings:
13On 9/6/2023 at 11:38AM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the licensed facility. The purpose of the visit was to deliver the finding for the above allegation. LPA met with Elijah Aquilina, Residential Counselor. LPA initially closed this complaint as unsubstantiated on 8/4/2023. During the course of the investigation, LPA conducted twelve confidential interviews. LPA reviewed C1 and C2's treatment plans, shift notes for 7/21/2023-7/22/2023, incident reports, and facility's program statement. Based on confidential interviews, C1 and C2 did engage in sexual behaviors in the facility. Based on confidential interviews, three of the four interviewed remembered the door being open at the time. The same three interviewees had stated that the interaction happened in about 15-minutes. Based on confidential interviews, the sexual behavior happened during "hygiene" time between 9-10PM before the 15-minute checks are conducted between 10PM-6AM. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Selena Hood LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: EVOLVE TREATMENT CENTER, LAFAYETTEFACILITY NUMBER: VISIT DATE: 09/06/2023

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

met_with: Elijah Aquilana


summary: Facility Evaluation

raw_content:
Narrative:
On 7/27/2023 at 10:40AM, Licensing Program Analyst (LPA) Selena Hood conducted a case management visit to the licensed facility. The purpose of this visit was to conduct a case management visit regarding an incident reported to Community Care Licensing (CCL) on 7/26/2023. LPA met with Savannah Sullivan, Operations Manager. Based on the incident report, a client in care had alleged that they had engaged in inappropriate touch with another client and had felt uncomfortable about the incident. LPA requested both client's Needs and Services plans, shift notes from 7/21/2023 and 7/22/2023, contact information for the reporting party, and contact information for on-shift staff members. One of the two clients involved had discharged to their other facility. LPA conducted five confidential interviews. LPA conducted an exit interview with Savannah Sullivan, Operations Manager at 11:50AM.


summary: Facility Evaluation

raw_content:
Narrative:
On 7-16-24 10:00AM, Licensing Program Analysts George Karkazis conducted an unannounced Annual/Random inspection at listed facility. LPA met with Angel Panlasigui, Operations Manager and toured the facility inside and out. The Group Home is licensed to serve 6 clients. Present during the inspection were 3 staff and 3 clients. At 10:55AM LPA Karkazis reviewed client and staff files. All staff and client files were complete, in good order and up to date. At 12:31PM, LPA Karkazis toured the facility. LPA Karkazis observed 3 bedrooms and 3 bathrooms. LPA observed facility license, personal rights, facility sketch, meal menu, and other forms posted on the walls throughout the facility. LPA Karkazis tested the water temperature and found it to be 116 degrees which is in range. The thermostat read 67 which is within range. Sharps were locked and chemicals were safely stored. There were two days of perishable foods and seven days non-perishable foods present. The medication was also stored and locked in the staff office, in a locked cabinet. The facility is in good repair and clean. LPA Karkazis interviewed 3 staff and 3 clients. At 12:55PM LPA Karkazis toured the backyard. LPA Karkazis observed a sealed swimming pool in which you can walk on . The swimming pool was used last week. The backyard was in good repair and clean. At this time there are no deficiencies. An exit interview was conducted, appeal rights discussed and a copy of this report was given to Angel Panlasigui, Operations Manager.

met_with: Angel Panlasigui, Operations Manager


summary: Facility Evaluation

raw_content:
Narrative:
On March 27, 2025, at 11: AM, Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced case management inspection at the above-referenced facility to follow up on a submitted Incident Report (IR). LPA met with Renee Nunes, Clinical Program Director. At the time of the visit, seven staff members and five clients were present. During the inspection, LPA interviewed the Program Director to obtain additional details regarding the incident and to clarify updates in the incident report. LPA verified that proper follow-up procedures were conducted through a review of shift notes and interviews. The IR was submitted regarding an incident that occurred on March 6, 2025. According to the report, (C1) experienced suicidal ideations and jumped from a staircase inside the facility. The Program Director explained that C1 became upset after being denied a home pass. At the time of the incident, C1 had only been at the facility for one week and was not yet eligible for a pass. While a risk assessment was being conducted, C1 suddenly got up without warning and ran toward the staircase. LPA confirmed that proper procedures were followed both before and after the incident. Prior to the jump, the county mobile crisis team (A3) had been contacted and was in route, as C1 was not complying with the established safety plan. During the visit, the Program Director provided LPA with copies of the safety plan and risk assessment for review. After the jump, staff promptly assessed C1's injuries and ensured that the client remained in place until emergency medical services (EMS) arrived. Due to C1's behaviors, a higher-level treatment facility was deemed necessary, and C1 has not returned to the facility. No violations of the California Code of Regulations, Title 22, Division 6 were cited during this inspection. An exit interview was conducted, and a copy of this report was provided to Renee Nunes, Clinical Program Director.

met_with: Renee Nunes - Clinical Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On August 12, 2025, at 2: PM, Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced case management inspection at the above-referenced facility to follow up on a submitted Incident Report (IR). LPA met with Alisa Anhold-Tung, Primary Therapist. At the time of the visit, eight staff members and five clients were present. During the inspection, LPA interviewed the Primary Therapist to obtain additional details regarding the incident and to clarify updates in the incident report. LPA verified that proper follow-up procedures were conducted through a review of shift notes and interviews. The IR was submitted regarding an incident that occurred on August 5, 2025. According to the report, staff discovered a napkin containing an unknown pill in the therapist's bathroom. Through confidential interviews, it was learned that a pill matching the one found in the therapist's bathroom was also discovered in a client's pants pocket along with THC vape pen. Interviews further revealed that clients have access to the therapist's bathroom either before or after a session, or when other bathrooms are occupied. As a follow-up to the incident, the home will continue to conduct body and drug checks on the suspected client. Immediately after the initial discovery, staff conducted a full house sweep and body checks, which led to the discovery of a matching individual pill in one of the clients' bathrooms. Through confidential client interviews, no one was able to confirm the identity of the pills. The suspected client was not present at the time of the visit. No violations of the California Code of Regulations, Title 22, Division 6, were cited during this inspection. An exit interview was conducted, and a copy of this report was provided to Alisa Anhold-Tung, Primary Therapist.

met_with: Alisa Anhold-Tung, Primary Therapist


summary: Facility Evaluation

raw_content:
Narrative:
On December 11, 2025, Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced inspection to amend and correct a licensing document and to inspect the pool fence repair. Upon arrival, LPA met with Operations Manager Mathew Xavier. LPA began the visit with a walk through of the home. The pool fence was observed to have a temporary repair using a sturdy zip tie which was mentioned in POC. Towards end of visit Pool repair staff arrived and installed new part. During the visit, clients and staff were observed participating in a group activity in the living room. The POC for the fence repair was cleared during today's visit. Additionally, LPA amended and corrected a report from a previous visit. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Operations Manager Mathew Xavier. His signature below confirms receipt.

met_with: Operations Manager, Mathew Xavier


summary: Facility Evaluation

raw_content:
Narrative:
On December 16, 2025, Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced inspection. Upon arrival, LPA met with Mathew Xavier, Operations Manager. The purpose of the visit was to obtain a signature for a corrected Plan of Correction (POC) document due to an error identified in FAS, clarify who is currently serving as the Administrator at the home, and review the submitted POC documents. During the visit, LPA obtained the required signature from Matthew Xavier and sent an amended copy of the POC to the facility. LPA also contacted Compliance Officer Devorah Weiss to confirm the current Administrator. It was disclosed that the approved Administrator has been Lauren McChesney. LPA also discussed missing staff documentation related to a submitted POC. The Compliance Officer expressed concerns about accessing records for staff who are no longer employed. LPA referenced Title 22, Section 80066(d) - Personnel Records, which states that all personnel records must be retained for at least three years following termination of employment. After reviewing this regulation, the facility agreed to submit the missing documentation before the end of the day. Additionally, LPA addressed outstanding annual fees and provided (PINs) for both this location and the Walnut Creek location. No deficiencies were cited on todays visit. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Mathew Xavier, Operations Manager, whose signature below confirms receipt.

met_with: Mathew Xavier, Operations Manager


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

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


summary: Facility Evaluation

raw_content:
Narrative:
On 10/28/2025 at 10:20a.m., Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced inspection. Upon arrival, LPA met with Operations Manager, Mathew Xavier and explained the purpose of the visit. LPA observed that three holes punched in the wall still have not been repaired. During the initial visit on 10/15/2025, LPA first observed the holes. They were again observed on 10/21/2025, at which time facility staff stated the repairs would be completed by the end of that week. As of today's visit, the holes remain unrepaired. The holes do not pose an immediate risk to clients in care; however, this resulted in a Type B deficiency under CCR, Title 22, Section 80087(a) - Buildings and Grounds. Please refer to LIC809-D for additional information. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Operations Manager, Mathew Xavier, whose signature below confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/5/ Licensing Program Analysts (LPAs) Jonathan Medina and Amee Li conducted an unannounced inspection. Upon arrival, LPAs met with Mathew Xavier, Operations Manager but he had to leave to attend matters at another home. Therapist, Lucy Marigold took over the licensing visit. During the physical inspection of the facility LPAs discovered that the fence for the pool was broken and had an opening. Due to pool regulatory requirements this is an immediate issue. This is a violation of California Code of Regulations (CCR), Title 22, Section 80087(a) - Buildings and Grounds. Please refer to LIC809-D for additional information. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Therapist, Lucy Marigold, whose signature below confirms receipt.

met_with: Therapist - Lucy Marigold


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
AT 9:57AM, Licensing Program Analyst (LPA) Madi Fremont traveled to Evolve Lafayette to conduct an unannounced Annual Inspection. LPA met with Administrator Brandi Ellis who helped facilitate this inspection. Currently in care are 5 ambulatory clients, all of which were present at the time of this inspection. During this inspection, LPA toured the home inside and out. The home is a 2 story house with 3 bedrooms, all of which are double occupancy. The home also has 5 bathrooms. Client Rights and Grievances were posted inside the front door for the facility. LPA confirmed that the bathroom downstairs off the main living room would remain unlocked for use at all times. The facility was observed to be clean and in good repair. LPA observed COVID-19 signs posted throughout the facility. There was a hand sanitizing station inside the front door. The front door is self latching with a dead bolt lock. There are security alarms on all client bedroom windows, and cameras in the interior and exterior of the home for security. Cleaning supplies, chemicals, and poisons are kept locked and inaccessible to clients. The weekly menu was on display in the kitchen. The home's emergency food supply was observed in the kitchen pantry, as well as dried food. The pantry door will remain locked. LPA observed at least 7 days of nonperishable food and at least 2 days of perishable food in the home. Exit signs were observed over all exit doors. The First Aid kit was observed in the nurse's station and contained all required elements. Laundry detergent is kept locked in a cabinet inside the laundry room. Medications are to be kept locked inside a safe, inside a locked cabinet, in the nurse's station, which will also remain locked. Client hygiene items and extra linens are kept in the hallway by the client bedrooms downstairs. (Continued on Lic809-c) All client bedrooms were observed to be clean and furnished with two twin beds each, and ample storage space for client belongings. The downstairs thermostat read 69 degrees Fahrenheit, and the upstairs thermostat read 70 degrees Fahrenheit. LPA measured the water temperature of the kitchen sink, which read 118 degrees Fahrenheit. LPA also measured the water temperature of the downstairs client bathroom sink, which measured 129.9 degrees Fahrenheit. A deficiency was cited per California Code of Regulations (CCR), Title 22, Division 6, Chapter 1, Article 7, Section 80088(e)(1) - Furniture, Fixtures, Equipment, and Supplies. Please see the attached LIC809-D for details. LPA also toured the backyard, and observed a pool with a retractable pool cover, which Administrator Brandi Ellis walked over to show it can support the weight of an adult. The pool cover is controlled by a key. The emergency water and gas shutoffs are located by the facility mailbox. The home backs up to a hill that slopes down from the property, which is bordered by a wooden fence. Fire extinguishers were observed in the gym, in the kitchen, at the top of both sets of stairs, outside the downstairs bathroom, and in the living room downstairs. All were inspected and approved in April, 2021. Smoke/Carbon Monoxide detectors were observed in the kitchen, dining room, in the upstairs therapy offices, and the clinical program director's office downstairs, and at the tops of both sets of stairs, and outside every client bedroom. Primary Therapists office are located upstairs. Exit plans are located at the top of the stairs, outside client bedrooms downstairs, and inside the front door. The home has an upstairs balcony, which will remain locked at all times and is not permitted for client use. All client bathrooms and bedrooms have frosted windows for privacy. The breaker and fuse boxes are located in the facility gym (garage) downstairs. All walkways were free from obstructions. No firearms on the property. LPA inspected 3 client files and 3 staff files, which were all complete with all required elements. At this time, one deficiency was observed and cited. An exit interview was conducted, Appeal Rights provided and discussed, and a copy of this report was emailed to Administrator Brandi Ellis, whose signature on this form confirms receipt.

Deficiencies:
80088: (e) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

met_with: Administrator Brandi Ellis


raw_content:
Narrative:
Additionally, the facility utilizes a level system in which clients may lose privileges for engaging in inappropriate behavior. The allegation regarding food being withheld as a form of discipline was reviewed. The food in question was banana bread, which was described as a treat prepared with clients as a reward for positive behavior. Staff reported, and LPA observed during visits, that fruit and cheese sticks are available to clients at all times. Although staff did not possess food handler certificates, staff had completed kitchen preparedness training which meets requirement. An exit interview was conducted, and a copy of this report was left with Operations Manager, Matthew Xavier whose signature on this form confirms receipt of the report. As a result, LPA Medina issued a Technical Violation under California Code of Regulations (CCR), Title 22, Division 6, Chapter 5, Section 80022(k), Plan of Operation. Please refer to the attached LIC TV. An exit interview was conducted, appeal rights were discussed, and a copy of this report was left with Operation Manager, Matthew Xavier whose signature on this form confirms receipt.

Investigation Findings:
13On 01/14/2026 at 10:30 a.m., Licensing Program Analyst (LPA) Jonathan Medina conducted a complaint inspection at the facility and met with Operations Manager, Matthew Xavier. The purpose of the inspection was to deliver the findings related to the above-referenced complaint allegation. Based on confidential interviews, facility-provided record reviews, and a review of the Plan of Operation/Program Statement, the preponderance of evidence standard was met. Therefore, the allegation that unqualified staff were supervising minors is SUBSTANTIATED. A review of staff files revealed that several Residential Counselors did not possess a bachelor's degree. The current Program Statement indicates that all Residential Counselors are required to have a bachelor's degree. Compliance Officer Devorah Weiss acknowledged this discrepancy and stated they are in the process of revising the Plan of Operation/Program Statement to reflect current staffing qualifications. The facility reported that this revision will be implemented across all 15 homes and will include this change. Continues on LIC9099-C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Jonathan Medina LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE This is an official report of an unannounced visit/investigation of a complaint received in our office on 10/15/2025 and conducted by Evaluator Jonathan Medina COMPLAINT CONTROL NUMBER: 14-CR- FACILITY NAME:EVOLVE TREATMENT CENTER, LAFAYETTEFACILITY NUMBER: ADMINISTRATOR:KELSEY LARSONFACILITY TYPE: ADDRESS: PANORAMA DRIVETELEPHONE: (323) 493- CITY:LAFAYETTESTATE: CAZIP CODE: CAPACITY:6CENSUS: 5DATE: 01/14/ UNANNOUNCEDTIME BEGAN: 10: AM MET WITH:Operations Manager, Matthew XavierTIME COMPLETED:10: AM 9Staff do not prevent minors from engaging in inappropriate communication Staff do not pevent minors from physically fighting with one another Staff use inappropriate form of discipline Facility is making false claims during the admissions process INVESTIGATION FINDINGS: 13On 1/14/2026 at 10:00 a.m., Licensing Program Analyst (LPA) Jonathan Medina conducted a complaint investigation visit to deliver the findings related to the above-referenced complaint allegations. LPA Medina met with Operations Manager, Matthew Xavier and explained the purpose of the visit. Based on confidential interviews, record reviews, and observations, the allegations may have occurred; however, there is insufficient evidence to support or refute that the alleged incident occurred. Therefore, the allegations are determined to be UNSUBSTANTIATED. The facility provided documentation verifying staff training in Pathological Demand Avoidance (PDA). A review of shift notes indicated that no clients were injured as a result of any disciplinary practices. No reports of physical fighting were identified through confidential interviews or documented in shift notes. All staff are trained in Crisis Prevention Intervention (CPI) techniques, which focus on de-escalation and redirection of inappropriate behavior. Confidential interviews revealed that staff actively intervene to prevent inappropriate communication among clients. Continues on LIC9909-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Jonathan Medina LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 2 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE FACILITY NAME: EVOLVE TREATMENT CENTER, LAFAYETTEFACILITY NUMBER: VISIT DATE: 01/14/2026

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

met_with: Operations Manager, Matthew Xavier


summary: Facility Evaluation

raw_content:
Narrative:
On January 30, 2026, Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced inspection at the request of the facility's Compliance Officer, Devorah Weiss, to review video footage related to an incident that occurred on November 8, 2026. Upon arrival, LPA met with Lucy Marigold, Therapist, who assisted in facilitating the inspection. Compliance Officer Devorah Weiss participated in the visit via telephone. During a prior case management visit on November 18, 2025, LPA requested access to the video footage; however, the footage was not made available at that time. During todays visit LPA again requested to review the video footage. Facility staff indicated that no one on-site was authorized to release or provide access to the footage. Additionally, Compliance Officer Weiss stated that the file size was too large to be transferred to a thumb drive. LPA inquired whether LPA can record video footage as an alternative; however, this request was declined. The Compliance Officer explained that programs attorney was uncomfortable releasing video footage that includes clients within the milieu. Although no copy of the video footage was provided, LPA scheduled a date and time to review the footage virtually with the Compliance Officer via Zoom on a later date. Facility staff reported experiencing technical difficulties with Verizon, which prevented the video from being viewed on-site. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Lucy Marigold, Therapist, whose signature below confirms receipt.

met_with: Lucy Marigold, Therapist


summary: Facility Evaluation

raw_content:
Narrative:
On February 10, 2026, at 10: AM, Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced annual/random inspection at the above listed facility. LPA Medina met with Emily Bell, Clinical Director, and conducted a comprehensive tour of the facility, both inside and outside. Compliance Officer, Devorah Weiss assisted with the inspection through Zoom to show client and staff files. The group home is licensed to serve six clients. Present during the inspection was 6 clients and several staff. At approximately 10:30 a.m., LPA conducted the physical plant portion of the CARE inspection tool. During the tour, LPA observed three bedrooms and three bathrooms. Required facility documents, including the license, grievance procedures, personal rights poster, facility sketch, meal menu, and other necessary postings, were properly displayed throughout the premises. Next to the clients' bathroom near the staff office, there was a hole in the wall. Staff stated it was from the previous night and that a work order had been submitted. LPA entered the kitchen at 11:00 a.m. and observed that all sharp objects and chemicals were securely locked, and trash was properly secured. The facility maintained the required food supply, including two days' worth of perishable food and seven days' worth of nonperishable food. Medication was locked in a cabinet in the nurse room. LPA tested the water temperature and found it to be 116 degrees Fahrenheit, which is within the required range. The thermostat read 68 degrees Fahrenheit, which is also within range. The facility has a pool in the backyard, and LPA observed that the fence was properly secured. There were no deficiencies noted in this portion of the inspection. Continues on LIC809-C At 12:00 p.m., LPA reviewed client and staff files and requested five of each at random. All facility records were kept digitally. Client files contained all necessary documents, including admission agreements, emergency information, medical and mental health assessments, Personal Rights forms, and client inventories. At 1:35 p.m., LPA reviewed staff files. LPA confirmed the program is still working on a Plan of Operation update to reduce the education requirements for the Residential Counselor position so that a bachelor's degree is not required. The previous Administrator, Lauren McChesney, who was on file, is no longer with the program as of 1/9/2026. The facility has a new Administrator on file. LPA observed the education requirements, Administrator Certificate, and job description for the Administrator. LPA advised the facility to submit all documents observed during the visit to process the new Administrator for future licensing records. In other staff files, LPA observed CPR certificates, health screenings, criminal record statements, and training documents. All staff were fingerprint cleared. No deficiencies were observed in the client or staff sections. At this time, no deficiencies were cited. Technical assistance was provided regarding the repair of the hole in the wall. The annual inspection was not completed during today's visit. LPA will return at a later date to complete the inspection and conduct interviews. An exit interview was conducted at approximately 3:30 p.m., and a copy of this report was provided to Emily Bell, Clinical Director. Signature on this report acknowledges receipt.

met_with: Emily Bell - Clinical Director


summary: Facility Evaluation

raw_content:
Narrative:
On 11/18/2025 at 1: PM, Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced inspection at the facility. Upon arrival, LPA met with Operations Manager Mathew Xavier and explained the purpose of the visit. LPA made a visit on 2/18/2026 to amend this report and met with Lucy Marigold, Therapist. The facility did not have staff training records available for Licensing review. This is a violation of California Code of Regulations (CCR), Title 22, Section 84066(b)(4), Personnel Records. Please review the LIC9102 for additional details. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Lucy Marigold, Therapist, whose signature below confirms receipt.

met_with: Lucy Marigold - Therapist


summary: Facility Evaluation

raw_content:
Narrative:
On 03/13/2026, Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced inspection to amend a licensing report given on 11/18/2025. Upon arrival, LPA met with Lucy Marigold, Therapist and informed them on the purpose of the visit. LPA began the visit with a walk through of the home. LPA amended the report. An exit interview was conducted, appeal rights were discussed, and a copy of this report along with amended report was provided to Lucy Marigold. Signature below confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
*** Report amended on 3/13/2026 *** On November 18, 2025, at 1: PM, Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced case management inspection at the above-referenced facility to follow up on a submitted Incident Report (IR). LPA met with Operations Manager Mathew Xavier. During the inspection, LPA interviewed staff and clients. The incident occurred on 11/08/2025 but was reported on 11/09/2025. According to the report, two clients were alleged to have engaged in inappropriate interactions. Both clients involved were interviewed during today's visit. Although staff were in the vicinity and within sight of the clients at the time of the incident, it was reported that both clients had a history of flirty behaviors. The clients had previously been assigned a 6-foot separation rule prior to the incident. One client was observed sitting next to the door of other clients room. In alignment with the 6-foot rule, the clients should have been relocated. As a follow-up to the incident, the facility will no longer allow hygiene time and medication time to occur simultaneously. Additionally, the facility held a staff debrief the following Thursday to discuss how staff can better prevent and respond to similar incidents in the future. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Operations Manager Mathew Xavier.


summary: Facility Evaluation

raw_content:
Narrative:
On 04/14/2026 at 2:50 p.m., Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced inspection at the facility and met with Emily Bell, Clinical Director to follow up on an outstanding Plans of Correction (POC). LPA Medina disclosed the purpose of the visit and was granted entry. At the time of the inspection, there was 5 staff member and 4 clients present. On 02/10/2026, LPA Medina conducted the facility's annual inspection. LPA has not received the POC for the following deficiency. California Code of Regulations, Title 22, Section 84064(c) Administrator Qualifications and Duties During today's visit, LPA Medina reviewed the Plan of Correction (POC) with Emily Bell. The POC was due on 03/18/2026. During the annual inspection, it was discovered through interviews that although the facility has an appointed administrator, the individual is based in Southern California and has not been present at the home since being assigned to the position. Ms. Bell, Clinical Director, explained that the facility is still seeking a more permanent administrative solution. She stated that Veronica Angel has made a visits since the POC was issued and completed tasks in accordance with the POC by the due date. LPA Medina contacted Compliance Officer Devorah Weiss for clarification regarding the current administrator. Ms. Weiss stated that another administrator, Lisa Faguet, has been assigned to the Lafayette home in place of Veronica Angel. Documentation outlining the dates Lisa Faguet was present at the home and the tasks completed will be emailed to LPA Medina by the end of the day. Supporting documents to get Lisa approved as facilities Administrator will also be sent to LPA by Ms.Weiss. Continues on LIC809-C LPA Medina also did a walk-through of the home and observed it was clean, in good repair, and observed the required regulatory amount of food in refrigerator and pantry. An exit interview was conducted. The report, along with appeal rights, was reviewed with and provided to Emily Bell. Signature on this report acknowledges receipt.


facility_name: EVOLVE TREATMENT CENTER, WALNUT CREEK

raw_content:
Narrative:
Minors are not treated with dignity Confidential interviews revealed conflicting statements that clients must leave the bathroom door ajar while using the restroom. Some confidential interviews reported that the clients did not have to leave the door open while using the restroom and other interviews stated that clients must leave the bathroom door ajar while using the restroom. It was noted in the facility's program statement that staff are to ensure that the clients keep the bathroom door ajar when using the restroom. Minors are not allowed hygiene items Confidential interviews revealed conflicting statements regarding whether clients are not allowed hygiene items. Interview information revealed that clients are given hygiene boxes that contain toothbrush, toothpaste, soap, shampoo, conditioner, deodorant, lotion, and other products which are available when the clients request them. Confidential interviews stated that clients are provided razors to shave but under the supervision of staff. It was noted in the facility's program statement that staff can withhold hygiene items from clients and provide them upon the request of the client depending on the client's level. Staff open minors' personal mail Confidential interviews indicated that the therapist keep all mail, unopened until the clients' next one-on-one therapy sessions. It was also disclosed that clients are required to open their letters in front of staff to make sure there is no contraband and confirmed that staff do not open clients' mails. Other confidential witnesses were unaware of the mail process and could not speak to this allegation. Some confidential witnesses stated that the clients open their personal mail in front of staff, and others stated the clients' primary therapists open their mail for them to screen letters and packages for contraband or triggering content. Minors not receiving an allowance Confidential interviews revealed that none of the minors received allowance during their residency at this Group Home. Per Facility Representative(s), the purpose of not providing clients allowance was to reduce the ability of incoming contraband. Facility Representative(s) also indicated that clients did not have a need for allowance as the Program provide the necessities for clients. Confidential interviews revealed that although allowance is not given, the facility provide for clients' needs which includes items while on outings. Minors are denied access to personal property Confidential interviews revealed that clients are denied personal property based on scheduled activities and for their safety. Some personal items are stored locked in a cabinet and made available to clients upon request. Per Facility Representative(s) some items such as razors require direct supervision, while other personal items (such as books, clothing and etc.) are not allowed to be possessed by clients because the item could trigger client's behaviors or jeopardize their safety while in treatment Based on the confidential interviews, observation, and record review, it has been determined that although the allegations that minors are not treated with dignity; minors are not allowed hygiene items; staff open minors' personal mail, minors not receiving an allowance, and minors being denied access to personal belongings may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. The program statement has been updated to ensure that the clients' needs will be met based on their individual assessments per Title Group Home Regulations. An exit interview was conducted, appeal rights discussed, and a copy of this report was provided to Taylor Culbertson.

Investigation Findings:
13On 12/02/2021 at 11:15AM, Licensing Program Analyst (LPA) Madeleine Fremont arrived at the facility to deliver the findings of a complaint investigation. LPA Fremont met with Administrator Taylor Culbertson and discussed the investigative findings. On June 7, 2021, the Department received a complaint alleging minors are not treated with dignity; minors are not allowed hygiene items; staff open minors' personal mail; minors are not receiving an allowance; minors are being denied access to personal property. Confidential interviews were conducted with 5 staff and 4 of 6 clients. Facility's Program Statement, Plan of Operation, Parent Handbook and Training Manual were reviewed. The following information was obtained during the course of the investigation: (CONTINUED ON LIC9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Madeleine Fremont LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: EVOLVE TREATMENT CENTER, WALNUT CREEKFACILITY NUMBER: VISIT DATE: 12/02/2021

met_with: Administrator Taylor Culbertson


raw_content:
Narrative:
Of the 5 clients that were interviewed regarding these allegations, all 5 clients stated they were given sufficient time for showering and personal/hygiene care. All clients reported that they were allowed more time for showering and hygiene based on their progress in the program, but that even at the minimum amount of hygiene time allotted after admission was enough time to complete their hygiene routine. Both staff who were interviewed reiterated this, reporting that even if the kids ran out of time in the bathroom, they were still given time outside of the bathroom with a vanity mirror to complete any hygiene tasks they had left. Of the 5 clients who were interviewed regarding these allegations, all 5 clients reported to this agency that they felt safe at Evolve, they had staff they were comfortable confiding in if needed, and that none of them had experienced any sort of sexual harassment from staff or other clients during their stay. All clients interviewed stated that supervision was heavily enforced and that they were never out of sight from staff, except when using the bathroom or showering. This agency has investigated the allegations (1) "Minor sexually harasses another minor;" and (2) "Minor not afforded sufficient time to perform personal care," and has found that although these allegations may be true or are valid, the preponderance of evidence standard has not been met, therefore the allegations are unsubstantiated, based on LPA's inability to contact the clients named in the original complaint at the time it was received. At this time, no deficiencies are observed or cited. An exit interview was conducted, and a copy of this report was emailed to Administrator Taylor Culbertson and Regional Nurse Ieshaa Ragland, whose signature on this form confirms receipt.

Investigation Findings:
13At 12:30PM, Licensing Program Analyst (LPA) Madi Fremont traveled to the home above for the purpose of conducting an unannounced complaint investigation inspection. LPA met with Regional Nurse Ieshaa Ragland, who helped facilitate this inspection. Currently in care are 7 ambulatory clients. (1 client was admitted this morning, and one client was discharged this afternoon. On 11/03/2021, the San Jose Children's Residential Program Regional Office received a complaint for Evolve Walnut Creek with two allegations: (1) "Minor sexually harasses another minor;" and (2) "Minor not afforded sufficient time to perform personal care." This complaint was investigated by LPAs Christopher Rollins and Madi Fremont. Over the course of this investigation, LPAs conducted interviews with 2 staff and 5 clients. LPA Fremont also attempted to interview all 6 clients who were present in the facility at the time this agency received this complaint, but was unsuccessful in making contact with any of those 6 clients. (CONTINUED ON LIC9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Madeleine Fremont LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CENTRAL COAST SC/RES, TRAEGER AVE., SUITE FACILITY NAME: EVOLVE TREATMENT CENTER, WALNUT CREEKFACILITY NUMBER: VISIT DATE: 10/27/2022

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

met_with: Regional Nurse Ieshaa Ragland


raw_content:
Investigation Findings:
13At 9:45AM, Licensing Program Analyst (LPA) Madi Fremont traveled to the home above for the purpose of conducting an unannounced complaint investigation inspection. LPA met with Chloe Jimenez in person and Devorah Weiss by telephone, who helped facilitate this inspection. Currently in care are 3 ambulatory clients. On 02/08/2023, the San Jose Children's Residential Program Regional Office received a complaint for Evolve Treatment Centers Walnut Creek with one allegation: "Facility does not have adequate staffing." This complaint was assigned to and investigated by LPA Fremont. Based on records review and interviews with staff and clients that show the facility has been utilizing a 1:6 staff-to-child ratio instead of the 1:3 ratio noted in the Licensee"s Plan of Operation, and reports that there was at least one incident when clients were left without staff at the facility for at least 30 minutes during a staff medical emergency, the allegation "Facility does not have adequate staffing" is found to be substantiated. A deficiency was cited per Title Regulations, Division 6, Chapter 1, Article 3, Section 80022(k) - Plan of Operation. Please see attached LIC9099-D for details. At this time, one deficiency was cited. An exit interview was conducted, Appeal Rights provided and discussed, and a copy of this report was emailed to Devorah Weiss and Chloe Jimenez, whose signature on this form confirms receipt. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Madeleine Fremont LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CENTRAL COAST SC/RES, TRAEGER AVE., SUITE FACILITY NAME: EVOLVE TREATMENT CENTER, WALNUT CREEKFACILITY NUMBER: 075650154

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

met_with: Chloe Jimenez and Devorah Weiss


raw_content:
Narrative:
According to seven confidential interviews and record review, the staff members on shift had separated the other clients in care from the one client that was having a behavioral episode (C1). According to these interviews, one staff member maintained engagement with C1 during this episode. According to record review and confidential interviews, the staff member working with C1 had called law enforcement when they had lost sight of the client. LPA was unable to interview C1 as they were hospitalized and then placed on long-term respite care. Based on two confidential interviews, the two interviewees relayed they did not have concerns with the facility's supervisory level of C1. Based on confidential interviews and record review, the clients in care were adequately supervised during the reported incident. The allegation that staff did not provide supervision of the clients to ensure health and safety in the facility may or may not have happened; however, it has not met the preponderance of doubt and is therefore unsubstantiated. LPA conducted an exit interview at 12:33PM over the phone with Devorah Weiss, Compliance Office. Compliance Officer approved that Candace Cruz, Senior Primary Therapist sign off on the report.

Investigation Findings:
13On 12/13/2023 at 11:55AM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the licensed facility. The purpose of this visit was to deliver the findings for the listed allegation. LPA met with Candice Cruz, Senior Primary Therapist. During the course of the investigation, LPA conducted sixteen interviews from October 30, 2023 to December 12, 2023. LPA reviewed C1's Needs and Service Plan, shift notes, staff schedule, and the Contra Costa County Sheriff's Office police report. Based on the record review of the staff schedule, the facility had two staff for six clients which was within ratio based on the facility's program statement. According to record review of the police report, law enforcement received an emergency call informing them that a client had eloped from the facility after a behavioral episode involving aggressive behavior and property damage. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Selena Hood LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO ASC, TRAEGER AVE., SUITE FACILITY NAME: EVOLVE TREATMENT CENTER, WALNUT CREEKFACILITY NUMBER: VISIT DATE: 12/13/2023

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

met_with: Candace Cruz


summary: Facility Evaluation

raw_content:
Narrative:
At 1:12PM, Licensing Program Analyst (LPA) Madi Fremont traveled to Evolve Walnut Creek for the purpose of conducting an unannounced Annual Inspection. LPA met with Facility Manager Ieshaa Ragland and Administrator Taylor Culbertson, who helped facilitate this inspection. Currently in care are 4 ambulatory clients, all of which were present during this inspection. During this inspection, LPA Fremont toured the facility inside and out. The home was observed to be clean and free of hazards. The home has two stories, with 4 client bedrooms, staff and therapy offices, a kitchen, living room, school room, nurse station, a spacious backyard, and a garage that has been turned into a gym and art room. All client bedrooms were clean, with designated storage space for each client. The client bathrooms were clean and free of hazards. Client hygiene items are kept in individually labeled bins in a locked cabinet in the upstairs hallway. LPA observed extra towels and linens in this closet as well. The nurses station remains locked, and contains the home's laundry machines, first aid kits, and centrally stored medications. The first aid kit is complete with all required elements. All medications are kept in a locked safe inside a locked cabinet. Each client's medications are separated into labeled bins. The kitchen was observed to be clean and free of food waste or debris. LPA observed at least 7 days of nonperishable food, at least 2 days of perishable food, as well as a backup supply of nonperishable food in case of emergencies. The weekly menu was posted in the kitchen. Client personal rights, the facility license, and the emergency disaster plan were all posted prominently. All smoke and carbon monoxide detectors were functional. The home has several fire extinguishers located throughout the facility. The gas and water shutoffs are located on the side of the house by the garage doors. The garage was equipped with an art station as well as a home gym for clients to utilize. (Continued on Lic809-c) The home has a spacious backyard which has several sitting areas for clients, as well as a basketball court, a lawn, and an in-ground pool. The pool is surrounded on all sides by a metal fence. The gate of this fence has a self-latching closure. All walkways were observed to be clear and free from obstructions. LPA observed the thermostat to be set at 75 degrees Fahrenheit. LPA observed the hot water temperature to be 117.4 degrees Fahrenheit. The home has two fireplaces, one of which is located in the upstairs staff office, and the other located in the school room. Both fire places are inoperable and are kept inaccessible to clients. The home is comfortably furnished with ample lighting and storage space. There are security alarms on all windows in the home, and security cameras in the interior and exterior of the facility. All cameras have been approved by Community Care Licensing and do not point toward any bedroom or bathroom. All chemicals and poisons are kept locked and inaccessible to clients. All sharps are kept locked and are tracked by a sharps checkout log. No firearms on the property. During this inspection, LPA Fremont reviewed 4 client files and 3 staff files. All client and staff files were complete with all required elements. At this time, no deficiencies were observed or cited. An exit interview was conducted, and a copy of this report was emailed to Administrator Taylor Culbertson, whose signature on this form confirms receipt.

met_with: Administrator Taylor Culbertson and Facility Manager Ieshaa Ragland


summary: Facility Evaluation

raw_content:
Narrative:
On 10/30/2023 at 2:17PM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the licensed facility. LPA was conducting an unrelated visit to the facility and was informed about an incident that occurred on 10/28/2023 where a neighbor had pointed a gun at the youth in care. LPA met with Savannah Sullivan, Operations Manager who helped facilitate the inspection. LPA conducted twelve confidential interviews. LPA requested copies of the staff schedule, daily notes, incident report, Needs and Services Plans, C1's face sheet, staff contact information, and security camera footage. At this time, further information is necessary. LPA conducted an exit interview with Savannah Sullivan, Operations Manager at 2:48PM whose signature confirms the receipt of this document.

met_with: Savannah Sullivan


summary: Facility Evaluation

raw_content:
Narrative:
On 4/19/2024 at 11:15am, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the licensed facility. The purpose of this visit was to conduct a case management based on an incident that was reported on 4/12/2024 (0000448-FN). LPA met with Niki Tata, Primary Therapist and Candice Cruz, Senior Primary Therapist. LPA conducted two confidential interviews. LPA did not conduct an interview with client involved based on therapist recommendation. Therapist requested that LPA return the following week. LPA received copies of the involved clients' face sheet. LPA requested clients' treatment plans, staff schedule for April 2024, daily notes for April 2024, and video footage be sent via email. LPA was informed that the video footage could not be sent, but Compliance Director Devorah Weiss could show the information via Zoom. No deficiencies were cited during this visit. LPA conducted an exit interview with Candice Cruz, Senior Primary Therapist whose signature confirms the receipt of this document.

met_with: Niki Tata


summary: Facility Evaluation

raw_content:
Narrative:
On 7-17-24, 9:30AM Licensing Program Analysts George Karkazis conducted an unannounced Annual/Random inspection at listed facility. LPA's met with Angel Panlasigui, Operations Manager and toured the facility inside and out. The Group Home is licensed to serve 6 clients. Present during the inspection were 3 staff and 6 clients. At 10:05AM LPA Karkazis reviewed client and staff files. All staff and client files were complete and in good order. At 10:34AM, LPA Karkazis toured the facility. LPA Karkazis observed 4 bedrooms and 4 bathrooms. LPA observed facility license, personal rights, facility sketch, meal menu, and other forms posted on the walls throughout the facility. LPA Karkazis tested the water temperature and found it to be 112.1 degrees which is in range. The thermostat read 66 degrees which is within range. Sharps were locked and chemicals were safely stored. There were two days of perishable foods and seven days non-perishable foods present. The medication was also stored and locked in the laundry room, in a locked cabinet, in a locked safe.. The facility is in good repair and clean. LPA Karkazis interviewed 2 staff and 3 clients, 3 clients refused interviews. At 10:59AM LPA Karkazis toured the backyard. LPA observed a swimming pool which was enclosed and locked with a fence that meets regulation. The backyard was in good repair and clean. At this time there were no deficiencies. An exit interview was conducted, appeal rights discussed and a copy of this report was given to Angel Panlasigui, Operations Manager.

met_with: Angel Panlasigui, Operations Manager


raw_content:
Narrative:
As a result, LPA Medina issued a Technical Violation under California Code of Regulations (CCR), Title 22, Division 6, Chapter 5, Section 80022(k), Plan of Operation. Please refer to the attached LIC TV. An exit interview was conducted, appeal rights were discussed, and a copy of this report was left with Haley Myers, Clinical Director whose signature on this form confirms receipt.

Investigation Findings:
13On 01/14/2026 at 11:30 a.m., Licensing Program Analyst (LPA) Jonathan Medina conducted a complaint inspection at the facility and met with Haley Myers, Clinical Director. The purpose of the inspection was to deliver the findings related to the above-referenced complaint allegation. Based on confidential interviews, facility-provided record reviews, and a review of the Plan of Operation/Program Statement, the preponderance of evidence standard was met. Therefore, the allegation that unqualified staff were supervising minors is SUBSTANTIATED. A review of staff files revealed that several Residential Counselors did not possess a bachelor's degree. The current Program Statement indicates that all Residential Counselors are required to have a bachelor's degree. Compliance Officer Devorah Weiss acknowledged this discrepancy and stated they are in the process of revising the Plan of Operation/Program Statement to reflect current staffing qualifications. The facility reported that this revision will be implemented across all 15 homes and will include this change. Continues on LIC9099-C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Jonathan Medina LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE FACILITY NAME: EVOLVE TREATMENT CENTER, WALNUT CREEKFACILITY NUMBER: VISIT DATE: 01/14/2026

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

met_with: Haley Myers, Clinical Director


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On February 20, 2026, at 1: PM, Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced case management inspection at the above-referenced facility to follow up on a submitted Incident Report (IR). LPA met with Haley Myers, Clinical Program Director. At the time of the visit, six staff members and six clients were present. During the inspection, LPA interviewed the Clinical Director to obtain additional information regarding the incident and to clarify updates documented in the incident report. The incident report was submitted for an event that occurred on January 24, 2026, involving a physical altercation between two clients in which one client punched another. During today's visit, LPA reviewed discharge documentation and conducted interviews to verify follow-up actions taken after the incident. The Plan of Operation states that physical altercations between clients may result in immediate discharge. The incident report documented that the clients were separated but did not specify the final outcome. Review of records confirmed the client identified as engaging in the physical aggression was discharged. Discharge documentation and referrals to alternative services were provided to the family. LPA determined proper procedures were followed during the incident and staff actively attempted to redirect clients prior to the altercation getting physical. Continues on LIC809-C During the walk through of the home, LPA observed that the pool area was not fully enclosed. Additional fencing and netting is required to ensure the pool remains inaccessible to clients. A deficiency was cited in accordance with California Code of Regulations (CCR), Title 22, Section 80087(e), Buildings and Grounds. The facility reported a padlock will be installed on the basketball court fence gate and additional zip ties will be added to secure the netting in the meantime until additional fencing is constructed. Additionally, LPA was informed that Lisa Faguet will serve as the interim Administrator instead of Veronica Angel. Haley Myers, Clinical Program Director, is in the process of obtaining an Administrator certificate and will assume the role upon completion. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Clinical Director Haley Myers. Signature on this report acknowledges receipt.

Deficiencies:
80087(e): (e)	All licensees serving children or serving clients... shall ensure the inaccessibility of pools, including swimming pools ...or similar bodies of water through a pool cover or by surrounding the pool with a fence.

met_with: Haley Myers - Clinical Director

title:
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780087(e) Building and Grounds


facility_name: EVOLVE TREATMENT VANALDEN

raw_content:
Narrative:
Minors are not allowed hygiene items Confidential interviews revealed conflicting statements regarding whether clients are not allowed hygiene items. Interview information revealed that clients are given hygiene boxes that contain toothbrush, toothpaste, soap, shampoo, conditioner, deodorant, lotion, and other products which are available when the clients request them. Confidential interviews stated that clients are provided razors to shave but under the supervision of staff. It was noted in the facility's program statement that staff can withhold hygiene items from clients and provide them upon the request of the client depending on the client's level. Staff open minors' personal mail Confidential interviews indicated that the therapist keep all mail, unopened until the clients' next one-on-one therapy sessions. It was also disclosed that clients are required to open their letters in front of staff to make sure there is no contraband and confirmed that staff do not open clients' mails. Other confidential witnesses were unaware of the mail process and could not speak to this allegation. Some confidential witnesses stated that the clients open their personal mail in front of staff, and others stated the clients' primary therapists open their mail for them to screen letters and packages for contraband or triggering content. Minors not receiving an allowance Confidential interviews revealed that none of the minors received allowance during their residency at this Group Home. Per Facility Representative(s), the purpose of not providing clients allowance was to reduce the ability of incoming contraband. Facility Representative(s) also indicated that clients did not have a need for allowance as the Program provide the necessities for clients. Confidential interviews revealed that although allowance is not given, the facility provide for clients' needs which includes items while on outings. Minors are denied access to personal property Confidential interviews revealed that clients are denied personal property based on scheduled activities and for their safety. Some personal items are stored locked in a cabinet and made available to clients upon request. Per Facility Representative(s) some items such as razors require direct supervision, while other personal items (such as books, clothing and etc.) are not allowed to be possessed by clients because the item could trigger client's behaviors or jeopardize their safety while in treatment Based on the confidential interviews, observation, and record review, it has been determined that although the allegations that minors are not treated with dignity; minors are not allowed hygiene items; staff open minors' personal mail, minors not receiving an allowance, and minors being denied access to personal belongings may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. The program statement has been updated to ensure that the clients' needs will be met based on their individual assessments per Title Group Home Regulations. An exit interview was conducted, appeal rights discussed, and a copy of this report was provided to Devorah Weiss.

Investigation Findings:
13On 12/02/2021 at 10: AM, Licensing Program Analyst (LPA) Miguel Gomez arrived at the facility to deliver the findings of a complaint investigation. LPA Gomez met with Administrator, Devorah and discussed the investigative findings. On June 7, 2021, the Department received a complaint alleging minors are not treated with dignity; minors are not allowed hygiene items; staff open minors' personal mail; minors are not receiving an allowance; minors are being denied access to personal property. Confidential interviews were conducted with 3 staff and 5 of 6 clients. Facility's Program Statement, Plan of Operation, Parent Handbook and Training Manual were reviewed. The following information was obtained during the course of the investigation: Minors are not treated with dignity Confidential interviews revealed conflicting statements that clients must leave the bathroom door ajar while using the restroom. Some confidential interviews reported that the clients did not have to leave the door open while using the restroom and other interviews stated that clients must leave the bathroom door ajar while using the restroom. It was noted in the facility's program statement that staff are to ensure that the clients keep the bathroom door ajar when using the restroom. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Miguel A Gomez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: EVOLVE TREATMENT VANALDENFACILITY NUMBER: VISIT DATE: 12/02/2021

met_with: Devorah Weiss