raw_content:
Narrative:
Confidential interviews reported conflicting statements of resident's participation in and recruiting of residents for CSEC activity. A second allegation alleging lack of supervision resulted in minor (Child #1 [C1]) AWOLing (Absent Without Leave) while in care was received by Community Care Licensing (CCL). Confidential interviews and record review provided conflicting reports of residents AWOLing while in care and how AWOLing is handled at the facility. Some confidential interviews denied AWOLing occurs while other confidential interviews reported staff attempt to discourage the residents from AWOLing by talking with the residents and attempting to redirect them. Confidential interviews and record review could not confirm or dispute the allegation. Community Care licensing (CCL) a third allegation alleging Minor (Child #1 [C1]) was being threatened by another minor (Child #2 [C2]) in care. Confidential interviews and record review provided conflicting reports of threats being made by C2 or any other resident in care. Confidential interviews reported C2 has a strong dominate personality and is a leader. Confidential interviews report residents followed C2 and did what C2 wanted to be accepted by C2, additional confidential interviews reported C2 uses C2's strong dominate personality to intimidate and threaten residents. Confidential interviews and record review could not confirm or dispute the allegation. Based on record review and confidential interviews the allegation of lack of supervision resulted in minor (Child #1 [C1]) engaging in CSEC (Commercially Sexually Exploited Children) activity while in care, lack of supervision resulted in minor (C1) AWOLing (Absent Without Leave) while in care, and Minor(C1) was being threatened by another minor (C2) in care may or may not have occurred, however they are not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of the report was provided along with appeal rights to Stella Maris Growth Center II Facility Manager, Tracy Mitchell.

Investigation Findings:
13On December 15, 2022 at 1:07pm Licensing Program Analyst (LPA), Nicole Strickland, met with Stella Maris Growth Center II Facility Manager, Tracy Mitchell, to deliver the findings for the above stated allegations. LPA Smith conducted an inspection of the facility on March 9, 2022 at approximately 3:30 pm and no immediate deficiencies were observed. The investigation included interviews with five foster youth (Child #1 [C1], Child #2 [C2], Child #3 [C3], Child #4 [C4], and Child #5 [C5]), five staff members (Staff #1 [S1], Staff #2 [S2], Staff #3 [S3], Staff #4 [S4], and Staff #5 [S5]) In addition, county records and facility records were reviewed. On March 8, 2022, Community Care Licensing (CCL) received an allegation alleging lack of supervision resulted in minor (Child #1 [C1]) engaging in CSEC (Commercially Sexually Exploited Children) activity while in care. Specifically it was reported when C1 was placed at Stella Maris Growth Center II, C1 was being sexually trafficked. Confidential interviews and record review could not confirm or dispute the allegation. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Nicole Strickland 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 19-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, MAIN ST., SUITE FACILITY NAME: STELLA MARIS GROWTH CENTER IIFACILITY NUMBER: VISIT DATE: 12/15/2022

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


state: CA

facility_name: STELLA MARIS GROWTH CENTER III

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Client #1 requested a couple of more minutes to finish getting dressed for work. At that time, Staff Member, Client #2, and Client #3 sat in the car while Client #1 finished. It was advised that as soon as Client #1 came outside, Staff Member began to pull out of the driveway and transport Client #2 to work. Information obtained from Administrator and County Social Worker stated the incident was not detrimental to the health and safety of Client #1 due to their age and behaviors. LPA received inconsistent information regarding the allegation as interviews deny C1 was left unattended and other interviews state C1 was left unattended for a short period of time at the facility. It was also reported that Administrator referred to client in an inappropriate manner and failed to treat client with dignity. It was reported that Administrator stated, "We can not treat you like a retarded infant." Administrator denied making the claim. Administrator stated he attempted to help Client #1 understand that their cooperation in the program would be beneficial to everyone. Administrator stated that he said Client #1 is not a child anymore. Information obtained from staff and county social worker stated that everyone treated Client #1 with dignity and respect, but there was always a complaint or issue. County Social Worker stated Client #1 was not satisfied with any placement, very defiant, and has a history of making false allegations in order to be removed. LPA Harris received inconsistent information regarding the allegations. Based on interviews and information obtained, Administrator referred to client in an inappropriate manner, Staff Member left Client #1 unsupervised, and staff failed to treat client with dignity, may or may not have occurred; therefore, the allegations are unsubstantiated at this time. Exit interview conducted and a copy of the report will be provided to the facility.

Investigation Findings:
13On November 10, 2021, Licensing Program Analyst (LPA), Jazmond Harris met with Facility Manager, Doris Santiago to deliver the findings for the investigation pertaining to the listed allegations. LPA Cheraki Davis initiated the investigation on April 28, 2021. During the investigation, LPA Davis conducted interviews with Out of Home Investigator and Client #1. LPA Harris interviewed Administrator, Facility Manager, Staff Member, County Social Worker, and Client #2. LPA Harris reviewed pertinent documentation. On April 21, 2021, Community Care Licensing (CCL) received information which stated Administrator referred to client in an inappropriate manner, staff left client unsupervised, and staff failed to treat client with dignity. It was reported that Client #1 was left at the home unattended and was told to stop "acting childish." It was also reported that staff failed to treat client with dignity. In regards to Client #1 being unattended, Client #1 was preparing to leave the home in order to go to work. It was advised that Client #1 had their own means of transportation. Due to the client ratio at the time, there was only one staff member there to transport the other client who also needed to go to work. Staff Member asked Client #1 to ride with the clients, but they refused. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Jazmond D Harris 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 19-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, MAIN ST., SUITE FACILITY NAME: STELLA MARIS GROWTH CENTER IIIFACILITY NUMBER: VISIT DATE: 11/10/2021

report_type: Complaint Investigation

met_with: Facility Manager-Doris Santiago

complaint_status: unsubstantiated


summary: Complaint Investigation - Unsubstantiated - 1 allegation

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Narrative:
that any client had to sit on the floor while being transported. Additional information corroborated that all vehicles were safe; seats and seat belts. LPA was unable to obtain detailed information regarding the allegation due to clients refused to be interviewed. Other confidential information received reported that the allegation was true. Based on interviews and information obtained, Facility Staff transported minor in an unsafe manner, may or may not have occurred; therefore, the allegations are unsubstantiated at this time. Exit interview conducted and a copy of the report will be provided to the facility.

Investigation Findings:
13On November 13, 2021 at 10: AM, Licensing Program Analyst (LPA) Jazmond Harris met with Facility Manager, Wanda Smalls to deliver the findings for the investigation pertaining to the listed allegations. LPA Harris initiated the investigation on June 24, 2021. During the investigation, LPA Harris conducted interviews with Facility Manager, Staff Members, and Client #3. LPA Harris attempted to interview additional clients, but they refused. LPA Harris also attempted to interview County Social Worker, Jasmine Alvarez, but LPA Harris was unable to obtain contact with the worker. LPA Harris observed and reviewed documents pertaining to vehicle inspections. On June 18, 2021, Community Care Licensing (CCL) received information which stated facility staff transported minor in an unsafe manner. Information obtained from interviews denied that the facility vehicles are unsafe. Information obtained stated that all vehicles are maintenance on a regular basis. Additional information stated that all vehicles had seats and belts. LPA Harris observed the facility vehicles and all the current facility vehicles had seats and belts. Information obtained from confidential interviews denied UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Jazmond D Harris 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 19-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, MAIN ST., SUITE FACILITY NAME: STELLA MARIS GROWTH CENTER IIIFACILITY NUMBER: VISIT DATE: 11/13/2021

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

met_with: Facility Manager-Wanda Smalls


raw_content:
Narrative:
granted by County Social Worker. Information obtained stated that staff always picked Client #3 up from the visit on the day that it was scheduled. Confidential information stated that Client #3 no longer has any supervised visitation with family members. It was noted that Client #3's unsupservised visitation was terminated due to inappropriate interaction with a sibling. It was denied that Client #3 had any overnight visit with biological family members. Information obtained from County Social Worker stated that Client #3 was allowed overnight visitations by staff members. County Social Worker was unable to advise when the visit occurred or how many times. County Social Worker stated she advised the facility administration during intake that Client #3 was not allowed to have overnight visitation with family members. County Social Worker denied that the information was documented; only verbally. LPA Harris was unable to determine if an overnight visit with Client #3's family was granted. LPA received inconsistent information regarding the allegation. Based on interviews and information obtained, Staff allowed Client #3 to have an overnight unsupervised visit, may or may not have occurred; therefore, the allegations are unsubstantiated at this time. Exit interview conducted and a copy of the report, along with appeal rights, will be provided to the facility.

Investigation Findings:
13On November 17, 2021, Licensing Program Analyst (LPA) Jazmond Harris conducted a visit to the facility and met with Facility Manager, Doris Santiago in order to deliver the findings for the listed allegation. LPA Harris initiated the investigation on June 24, 2021. During the investigation, LPA Harris conducted interviews with Facility Manager, Staff Member, two out of six clients, and County Social Worker. LPA Harris attempted to interview additional clients, but they refused. LPA Harris was also unable to interview additional witnesses pertaining to the allegation. LPA Harris observed and reviewed documents pertaining to visitation. On June 22, 2021, Community Care Licensing (CCL) received information which stated facility staff allowed minors to have unsupervised visits. It was reported that Client #5 (See Confidential Names List (LIC 811) dated November 16, 2021) had an unsupervised visit. It was later reported that Client #3 had an overnight unsupervised visit. Information obtained from staff stated that Client #3 was granted two hour visitation with biological father. It was denied that Client #3 ever was granted permission to spend a night with biological father. Further information obtained stated that Client #3 did ask for additional time for visitation and it was UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Jazmond D Harris 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 19-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, MAIN ST., SUITE FACILITY NAME: STELLA MARIS GROWTH CENTER IIIFACILITY NUMBER: VISIT DATE: 11/17/2021


raw_content:
Narrative:
On May 25, 2022, Community Care Licensing received a complaint alleging that staff did not prevent the spread of lice, shampoo is not accessible to minors, and staff did not provide a client with a safe place to store personal belongings. Regarding the allegation that staff did not prevent the spread of lice, a confidential interview stated that C1 was provided a head lice shampoo treatment at the STRTP. Confidential interview continued stating that staff combed C1's hair daily. Confidential interview added that C1's lice problem did not go away and C1's former resource mother was treating C1's lice outside of the facility. Another confidential interview stated that C1 did not have lice while placed at the facility, however, another client placed at the facility came into placement with lice and was being treated for lice when C1 was placed at the facility. Confidential interview continued stating that C1 was concern about the client's head lice and was fearful that lice could spread at the STRTP. A confidential interview stated not knowing if C1 had lice when placed at the facility. Confidential interview continued stating that C1 did not report issues with lice. Confidential interview continued stating that CSW may have gotten a report of C1's lice but could not recall. In regard to shampoo not being accessible to minors, a confidential interview stated that STRTP staff provided shampoo, but it was locked inside the STRTP's office. Confidential interviews indicated that currently all clients have personal boxes that contain a variety of hygiene products. Confidential interviews continued stating that although when C1 was placed at the facility shampoo was kept locked in the office, but staff provided shampoo to clients upon request. Concerning staff not providing a minor with a safe place to store personal belongings allegation, a confidential interview stated that C1's personal belongings were stored in C1's bedroom. Confidential interviews stated that clients have storage space in their rooms, and dressers where clients can store personal belongings. A confidential interview stated that C1 did not report concerns about not having a safe place to store personal belongings. Based on confidential interviews, the allegations that staff did not prevent the spread of lice, shampoo is not accessible to C1, and staff does not provide C1 with a safe place to store personal belongings, may have occurred, however, there was not a preponderance of evidence to support or deny the allegations, therefore, the allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to STRTP's Lead Facility Manager, LaKeicha Chaney.

Investigation Findings:
13On October 4, 2022, at 8: AM, Licensing Program Analyst (LPA) Cynthia Urena met with Stella Maris III Lead Facility Manager, LaKeicha Chaney to deliver the investigative findings for the above stated allegations. On May 25, 2022, at 1:00PM, Licensing Program Analyst (LPA) S. Smith initiated the investigation at Stella Maris III Short Term Residential Therapeutic Program (STRTP). At 1:30PM LPA S. Smith conducted a health and safety inspection, and no immediate hazards were observed. On August 31, 2022, at 4: PM, LPA C. Urena conducted interviews with two staff members at the STRTP, LPA C. Urena attempted to interview two clients, however, both clients refused to be interviewed. On September 28, 2022, LPA C. Urena interviewed a County Social Worker (CSW), and on September 29, 2022, LPA C. Urena conducted a collateral interview with one client. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Cynthia Urena 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 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: STELLA MARIS GROWTH CENTER IIIFACILITY NUMBER: VISIT DATE: 10/04/2022

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

met_with: Lead Facility Manager- LaKeicha Chaney


raw_content:
Narrative:
During the investigation, Confidential interviews stated that staff have expressed concerns to management about C3's ongoing behaviors, however, nothing has been done. Confidential interviews stated that C3 bully's clients, likes to stir up conflict among clients and threatens other clients. Confidential interviews stated that S3 and S4 have a relationship with C3's family members that is causing the program from removing C3 from placement. Confidential interviews further stated that the relationship between C3, S3 and S4 is affecting consequences to be enforced. A confidential interview stated that if S3 and S4 did not have a relationship with C3's family members C3 would have been removed from placement due to ongoing behaviors that have placed other clients at risk. A confidential interview stated that the altercation that occurred between C1, C2, C3, and C4 was due to C3 stirring up conflict among clients. Confidential interview further stated C1 has spoken up about the issues with C3 and C4, but it has not made a difference. Confidential interview further stated that when C1 has spoken up about the issues it has made C3 and C4 more upset. A confidential interview stated that there is a staff member at the STRTP that has a relationship with C3's family and has been cleared for placement of C3. Confidential interview further stated that management from C3's County Social Worker and management for the STRTP are aware of the relationship. Based on confidential interviews, the preponderance of evidence standard has been met, and the allegation that staff are not providing a safe environment for minors is supported and proven by evidence. The facility is cited for violation of Short-Term Residential Treatment Facility (STRTP) Interim Licensing Standards Section 87072(c)(11) PERSONAL RIGHTS. Exit interview was conducted. A copy of this report, LIC 811, and appeal rights were explained and provided to Facility Manager, Doris Santiago During the investigation, a confidential interview stated that S5 and S6 were present during the altercation and attempted to diffuse the fight but were unsuccessful. Confidential interview further stated that S5 called law enforcement and reported the incident to management. Other confidential interviews stated that when staff witness a physical altercation among client's, staff are trained to break up the fight, talk to clients, and conduct group meetings with clients and staff to address the situation further. Another confidential interview stated that S1 assisted C1 in obtaining medical attention after the altercation. A confidential interview stated that C3 instigated the altercation between C1 and C2. Another confidential interview stated that C3 and C4 made the situation worst which resulted in C1's overall injuries. Another confidential interview stated that staff did not report the altercation to C1's county social worker. Confidential interview further stated that C1's county social worker found out about the altercation through a third party. Confidential interview continued stating that shortly after the altercation there was a meeting conducted and program staff did not have a solid plan. Confidential interview further stated that program staff were back and forth on whether to remove C3 from placement or not. Other Confidential interviews admitted that C1 and C2 were involved in a verbal altercation earlier in the day. Another confidential interview stated that C1 did not expect to get "jumped" by all three clients later that evening. Confidential interview further stated that staff were aware of the issues that were occurring between C1, C3 and C4. Based on the confidential interviews, the allegation that minors engaged in a physical altercation resulting in injuries due to lack of supervision, may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Facility Manager, Doris Santiago.

Investigation Findings:
13On December 5, 2022, at 11: AM, Licensing Program Analysts (LPAs) Cynthia Urena and Karen Beal met with Stella Maris Growth Center III Short Term Residential Therapeutic Program (STRTP) Facility Manager, Doris Santiago, to deliver the investigative findings for the above stated allegation. On September 12, 2022, at 09: AM, Licensing Program Analyst (LPA) Cynthia Urena initiated the investigation at the STRTP. LPA Urena conducted a health and safety inspection, and no immediate deficiencies were observed. Additionally, LPA Urena interviewed four staff and three clients. On December 1, 2022, LPA Urena interviewed two County Social Workers, and on December 2, 2022, LPA Urena interviewed a staff member. On September 7, 2022, Community Care Licensing received a complaint alleging that staff are not providing a safe environment for minors. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Cynthia Urena 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 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: STELLA MARIS GROWTH CENTER IIIFACILITY NUMBER: VISIT DATE: 12/05/2022

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: Facility Manager, Doris Santiago


raw_content:
Narrative:
On October 11, 2022, Community Care Licensing received a complaint alleging that staff uses profanity towards minors and staff makes minors feel uncomfortable. In regard to the allegation that staff uses profanity towards minors, it was specified that S4 uses profanity towards clients. Confidential interviews denied that S4 uses profanity when speaking to clients. Confidential interviews further stated that C1 and C3 have not expressed concerns or stated that S4 was using profanity when speaking to clients. Confidential interviews stated that S4 was liked by clients and clients engaged in therapy sessions without concerns. A confidential interview stated that S4 was using profanity when speaking to C3. Confidential interview continued stating that S4 intimidated C3 when C3 talked back to S4. A confidential interview stated that during one-on-one visits with C1's County Social Worker, C1 has not expressed concerns about S4. Confidential interview further stated that C1 is very open and informs County Social Worker about everything but C1 has not reported any problems or concerns with staff. Confidential interview also stated that C1 has asked County Social Worker to stay in the program and expressed liking the placement. Another confidential interview further stated that C1 and C3 became aggressive towards S4 after S4 requested the removal of C3 from the program. Confidential interview further stated that C1 and C3 attempted to attack S4 due to S4's comments during a meeting. Another confidential interview stated that S4 was observed being professional and engaging well with clients. Another confidential interview stated that clients are the ones that use profanity during therapy sessions when expressing emotions. Regarding the allegation that staff makes minors feel uncomfortable, confidential interviews reported feeling comfortable around S4. Confidential interviews stated that the reason clients participate in therapy sessions was due to S4 making clients feel comfortable. Confidential interviews reported that staff have not heard about any statements or comments from clients that S4 makes clients feel uncomfortable. A confidential interview denied being inappropriate with C1 and C3. Confidential interview further stated that when S4 addresses clients it is with a trauma informed approach. Confidential interview further stated that C3 would become jealous when S4 would not speak to C3 first. Confidential interview further stated that clients and staff have made comments when C3 refers to S4. Another confidential interview stated that S4 made C3 feel uncomfortable due to the questions being asked and the way S4 looks at C3. Another confidential interview stated that it was difficult to pinpoint the truth due to client's behaviors and history of lying. Continued on LIC C page 3... Based on the confidential interviews, the allegations that S4 uses profanity towards clients, and S4 makes clients feel uncomfortable, may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Facility Manager, Doris Santiago

Investigation Findings:
13On December 5, 2022, at 11: AM, Licensing Program Analysts (LPAs) Cynthia Urena and Karen Beal met with Stella Maris Growth Center III Short Term Residential Therapeutic Program (STRTP) Facility Manager, Doris Santiago to deliver the investigative findings for the above stated allegations. On October 20, 2022, at 10: AM, Licensing Program Analyst (LPA) Cynthia Urena initiated the investigation at the STRTP. LPA Urena conducted a health and safety inspection, and no immediate deficiencies were observed. LPA Urena conducted interviews with two staff members. LPA Urena attempted to interview two clients however, both refused to be interviewed. Additionally, at 12: PM, LPA Urena conducted two collateral interviews. On November 3, 2022, LPA Urena interviewed a client (C5) three staff members (S S2 and S3)and attempted to interview an additional client. On December 1, 2022, LPA Urena interviewed a County Social Worker and on December 2, 2022, LPA Urena interviewed a staff member (S4) Continued on LIC C page 2... UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Cynthia Urena 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 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: STELLA MARIS GROWTH CENTER IIIFACILITY NUMBER: VISIT DATE: 12/05/2022

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


raw_content:
Narrative:
The interviews that were provided to the LPA were not consistent and did not provide any specific details regarding lack of supervision and staff falsifying client's documents. Based on interviews and record reviews the allegations that due to lack of supervision the clients are absent without leave (AWOL) from the facility and S1 is falsifying the client's documents, may have occurred, however is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to LaKeicha Chaney.

Investigation Findings:
13On February 8, 2023 at 12:31pm, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced inspection to the facility to deliver the findings of the above allegations. LPA met with LaKeicha Chaney. LPA Sarah Smith conducted an inspection of the facility on February 17, 2022 at 1:32 pm and no immediate deficiencies were observed. Three of three clients (C1, C2, C3), four staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that due to lack of supervision the clients are absent without leave (AWOL) from the facility and S1 is falsifying the client's documents. Confidential staff interviews reported that staff verbal counsel all of the clients prior to AWOLing. Confidential staff interviews reported that staff will physically follow the clients until staff loses sight of them. Confidential interviews reported that staff does not falsifying any information about the clients to any entity or department. Additional information reported that staff will lie about the client's (known name) to law enforcement and the clients authorized representative. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz 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 19-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, MAIN ST., SUITE FACILITY NAME: STELLA MARIS GROWTH CENTER IIIFACILITY NUMBER: VISIT DATE: 02/08/2023

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

met_with: LaKeicha Chaney


raw_content:
Narrative:
Continued from LIC 9099 pg 1** On January 26, 2023, LPA Urena interviewed another client (C2) and attempted to interview client#3 (C3). On February 1, 2023, LPA Urena interviewed client#4 (C4) and attempted to interview client #5 (5). During investigation, a confidential interview stated that staff use personal money when taking clients out on outings but stated that staff are reimbursed for the expenses at a later date. Other confidential interviews stated that there were times when client's outings were canceled due to the limited funds available for outings. Another confidential interview stated that Licensee provides S1 with weekly funds for outings that were scheduled for the week. Other confidential interviews reported that clients go out and funding is provided for client outings. Based on the confidential interviews, the allegation that staff are not ensuring they have enough money for outings may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Head of Service, Ogechi Nkwocha

Investigation Findings:
13On February 8, 2023, at 10: AM, Licensing Program Analyst (LPA) Cynthia Urena met with Stella Maris Growth Center III Short Term Residential Therapeutic Program (STRTP) Head of Service, Ogechi Nkwocha to deliver the investigative finding for the above stated allegation. On November 28, 2022, Community Care Licensing received a complaint alleging that staff are not ensuring they have enough money for outings for the minors. On December 5, 2022, at 9: AM, Licensing Program Analysts (LPAs) Cynthia Urena and Karen Beal initiated the investigation at the STRTP. LPAs conducted a Health and Safety inspection, and no immediate deficiencies were observed. LPA Urena obtained copies of the Short-Term Residential Therapeutic Program staff and client files and interviewed three staff (S1, S2, S3) and one client (C1). **Continued on LIC C pg 2** UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Cynthia Urena 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 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: STELLA MARIS GROWTH CENTER IIIFACILITY NUMBER: VISIT DATE: 02/08/2023

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

met_with: Head of Service, Ogechi Nkwocha


facility_name: STEPSS RESIDENTIAL FACILITY FOR YOUTH

summary: Facility Evaluation

raw_content:
Narrative:
On December 09, 2025, Licensing Program Analysts (LPA) Cynthia Robinson and Licensing Program Manager (LPM) Cheraki Davis met with STEPSS Residential Facility for Youth, applicant Regina Napper to complete Component II, the face-to-face interview, for the Short Term Therapeutic Residential Program (STRTP) application process. Also present were prospective Administrator, Hilary Moffet and prospective Administrator Assistant, Arsema Clayton. The applicant previously attended Component I, the STRTP orientation, on November 22, 2022. The purpose of today's meeting was to address any questions or concerns and to review the application packet and process, ensuring that the applicant, designated administrator, and all relevant parties understand and can provide the services outlined in the Program Statement and Plan of Operations in compliance with Community Care Licensing regulations. LPA reviewed the application documents, addressing and correcting discrepancies on the LIC forms required for STRTP application. Policies and procedures submitted as part of the application, including discipline policies, program description, population to be served, and personal rights, were also reviewed. The facility staff plan was discussed to ensure compliance. The applicant does not yet have direct care staff but stated that a temporary staffing plan is in place. LPA provided the applicant with the corrections of the submitted LIC forms, Plan of Operation and Program Statement. LPA informed the applicants and attendees of the next steps in the application process and applicants stated they will work on revisions and submit by December 19, 2025. An exit interview was conducted, and a copy of this report was provided to the applicant.

report_type: Facility Evaluation

met_with: Applicant, Regina Napper


summary: Facility Evaluation

raw_content:
Narrative:
On May 06, 2026, at 10:30am, Licensing Program Analyst (LPA) Cynthia Robinson arrived announced at the above facility for the purpose of conducting Pre-licensing inspection at the facility. LPA was greeted by Regina Napper, Applicant and Hilary Moffett, Interim Administrator. The Licensee above submitted a Short Term Residential Therapeutic Program (STRTP) application. Presently there are no clients in care at the proposed new location. The STRTP has an approved capacity of six and has obtained the fire clearance. The age range for the clients are 6-12. The pre-licensing facility physical inspection was conducted with Regina Napper and Hilary Moffett. The facility is a two-story home with five bedrooms and four bathrooms, and a two-car garage. The facility has a living room and dining room in the kitchen area with a large dining room table. There are currently no cameras in the facility but per Applicant statement they will be purchasing cameras. Applicant was reminded of the video camera requirements per PIN 24-09-CRP. There is one smoke detector and carbon monoxide combination located in the downstair hallway. There is a landline telephone that is in working order that will be available to clients. There were no observable hazards or obstructions by the other walkways and entries/exits. There is one sliding door exit in the dining room/living room leading to the backyard. There are no pools of bodies of water present. The backyard has artificial turf and concrete. LPA observed potential hazards on the side of the house. Per Applicant, a large bulk order was requested to be picked up to have it removed. The central ac unit is in the backyard behind the house located on the right side of the house. The Applicant has a working fire extinguisher located by the kitchen. The garage will be made inaccessible to clients. There is one room downstairs next to the front entry that will be utilized as the Therapist room. The Therapist room has a working sink and dishwasher and its own exit leading outside. Per Applicant, the room will be made inaccessible to clients without staff supervision. (Continued on LIC 809C...) The bedrooms will be arranged so that no more than two clients are in a room, and there will be one client per bed. There is a downstairs laundry that will be made available for client use. There is one bedroom (bedroom #1) that will be used for two clients and one full bathroom (bathroom #1) downstairs that will be available for client use. An additional powder room is available for clients use downstairs. There are three bedrooms upstairs and two full bathrooms. Two of the bedrooms will be utilized for client use and have two beds per room. All bedding was found to be in ready condition. The Applicant was advised that all individual beds must be in good repair, equipped with good springs, clean mattresses, and pillows. LPA tested the water, and it read at 107 degrees Fahrenheit. The Applicant was advised that the hot water should measure within 105 degrees Fahrenheit and 120 degrees Fahrenheit. The third bedroom will be utilized as the staff office and currently has one desk and one dresser. Per Applicant statement the staff office will have more locked cabinets and another staff desk available. There is an additional laundry room that is located upstairs, has ample storage space and per Applicant statement will contain chemicals cleaners and client toiletries. The laundry door is not yet made inaccessible to clients but per Applicant statement the facility will update the doorknob to ensure it's a locked room. Per Applicant statement, medication will be centrally stored in a locked box located in the staff office. LPA observed the staff office door not to have a locked door. Per Applicant statement the facility will purchase new doorknobs to ensure that the staff office will be made inaccessible to clients. LPA observed the facility did not have any knives for the facility use. Per Applicant statement the facility will be purchasing some knives and will be stored in a downstairs linen closet and made inaccessible. LPA did not observe the linen closet a locked door. Per Applicant, the facility will update the doorknobs to be made inaccessible. The Applicants has sufficient dishes, cups and silverware for client use and the gas stove is in working order. LPA did not observe age-appropriate books, games, and puzzles for clients. Per Applicant statement, the facility will purchase more games, books and puzzles for the clients. LPA did not observe any personal hygiene items available for the clients. LPA did not observe 7 days of non-perishable foods available. LPA did not observe a food menu posted. LPA did not observe a facility sketch posted. LPA observed cleaning supplies underneath the kitchen sink that is accessible to clients. Per Applicant statement, all changes will be made to ensure facility is in compliance. Please note the facility is in a residential community that contains a Homeowners Association (HOA). Per Applicant, they previously had a conversation with HOA that gave verbal permission to open the STRTP facility. LPA advised to receive a written agreement from HOA that permits the home to run the STRTP facility. Per Applicant statement, they will request the letter of agreement. The facility has one van that seats up to sixteen passengers that was present for transportation for clients and is in good working condition. LPA will return to the facility to ensure all changes are made. A copy of this report was given to the Applicant, Regina Napper.

visit_type: Prelicensing

met_with: Regina Napper, Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On May 15, 2026, at 10:00am, Licensing Program Analyst (LPA) Cynthia Robinson arrived announced at the above facility for the purpose of conducting second visit for Pre-licensing inspection at the facility. LPA was greeted by Regina Napper, Applicant and Hilary Moffett, Interim Administrator. The Licensee above submitted a Short Term Residential Therapeutic Program (STRTP) application. Presently there are no clients in care at the proposed new location. The STRTP has an approved capacity of six and has obtained the fire clearance. The age range for the clients are 6-12. The pre-licensing facility physical inspection was conducted with Regina Napper and Hilary Moffett. On 05/06/2026, LPA Robinson conducted the initial Pre Licensing visit and observed the facility missing the following during the physical plant walk through: LPA observed the facility did not have any knives for the facility use. LPA did not observe the linen closet a locked door. LPA did not observe age-appropriate books, games, and puzzles for clients. LPA did not observe any personal hygiene items available for the clients. LPA did not observe 7 days of non-perishable foods available. LPA did not observe a food menu posted. LPA did not observe a facility sketch posted. LPA observed cleaning supplies underneath the kitchen sink that are accessible to clients. LPA observed potential hazards on the side of the outside house. (Continued LIC 809C...) On today's visit, 05/15/26, LPA conducted another physical walk through of the facility and observed that the facility obtained knives, and they were made inaccessible to the clients located in a locked linen closet. LPA observed the facility had a small number of games, books and puzzles. Per Applicant, the facility will continue to purchase more books, games, and puzzles that are age appropriate. LPA observed the facility had personal hygiene items available for clients. LPA observes the facility had 7 days of non-perishable foods available. LPA observed a sample menu posted. LPA observed cleaning supplies made inaccessible for clients where they are stored in a locked linen closet. LPA observed that the potential hazards were cleared and there are no potential hazards outside of the house. A final file review will be conducted, and the facility will be submitted for licensure. Pre-Licensing inspection was completed, and a copy of this report was given to the Applicant, Regina Napper.

met_with: Regina Napper, Applicant


facility_name: STOCKDALE BOYS CENTER

raw_content:
Narrative:
However, when the client is out on community pass, C1 does not watch their insulin and consume whatever they want to eat. C1 was taken to the hospital due to high sugar levels; C1 is not calculating intake of carbs. When C1 was first placed at the facility, staff cooked and prepared separate meals for them but they refused to eat. The physician informed C1 can have whatever they want to eat and check blood sugar levels and adjust with insulin. Trained staff observe the administration of insulin. Insulin is self-administered by the client. Statements obtained from the confidential interviews did not provide sufficient information to corroborate the allegation. Based on the information gathered, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that alleged violation occurred, therefore the allegation is unsubstantiated. There were no deficiencies cited during this inspection. An exit interview was conducted. Appeal rights explained and a copy of this report, and Appeal Rights were provided to the facility representative.

Investigation Findings:
13On December 14, 2023, at 4: PM, Licensing Program Analyst (LPA) Karen Suh conducted a follow-up complaint inspection to deliver the finding of a complaint investigation. The LPA met with the representative named above and discussed the finding. The investigation included confidential interviews that consisted of but were not limited to: Administrator, three staff, and two clients on June 7, 2023. The LPA was unable to contact the County Social Worker (CSW) after several attempts. The LPA reviewed Needs & Services Plan, Child and Family Team (CFT) Meetings, Blood Glucose Target Range, Blood Sugar Logs, 90-day Clinical Reviews, Intensive Care Coordination (ICC) Service Note, and material about diabetes; medications, checking the blood sugar, insulin for client (C1, see Confidential Names LIC 811, dated December 14, 2023). It was alleged that facility staff did not assist minor with their medical issue. Staff denied the allegation stating client's insulin intake is checked every four hours. Staff check and watch C1's insulin and diet. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Karen Suh 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: STOCKDALE BOYS CENTERFACILITY NUMBER: VISIT DATE: 12/14/2023

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

met_with: Yolanda Hernandez, Rehabilitation Specialist


raw_content:
Narrative:
The Administrator indicated that they were unaware of an incident regarding this allegation and that no one had disclosed this type of incident. The Administrator specified that they were surprised at the allegation, because Ref. #2 was afraid of Ref. #1. The LPA was unable to obtain sufficient evidence to corroborate the allegation. There was no preponderance of the evidence to substantiate the allegation. So, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the allegation is unsubstantiated. There are no deficiencies to be cited regarding this allegation. A copy of this complaint was provided to the facility representative.

Investigation Findings:
13On August 14, 2025 at 3:35 p.m., Licensing Program Analyst (LPA), Karen McGee, delivered the findings of a complaint investigation involving Clients (see Confidential Names, LIC Ref. #1 and #2 dated August 14, 2025). The LPA met with Administrator, Marcy Mardison and Supervisor, Delphine Luster. On May 5, 2025, Monterey Park Children's Residential Program (MPCRP), received a complaint with the above mentioned allegations. Confidential interviews were conducted that included, but were not limited to: two clients, Ref. #1 at the facility on May 7, 2025 and Ref. #2 at the new placement on May 28, 2025; the Administrator on August 6, 2025. After a few attempts the LPA was unable to contact the clients' authorized representatives. The LPA reviewed the clients' Needs & Services Plan and incident reports. There was a statement that Ref. #2 pulled a knife on Ref. #1 and threatened Ref. #1 if Ref. #1 did not perform oral copulation on Ref. #2. Ref. #1 refused to participate in the investigation. Ref. #2 denied the allegation. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Karen McGee LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: STOCKDALE BOYS CENTERFACILITY NUMBER: VISIT DATE: 08/14/2025

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

met_with: Marcy Madison


summary: Facility Evaluation

raw_content:
Narrative:
On 10/26/2020 at 11: AM, Licensing Program Analysts (LPAs) Juliet Robles and Janeth Chavez conducted a post-licensing virtual inspection of the Short Term Residential Therapeutic Program (STRTP) and met with the Administrator Marcy Madison. The (LPAs) along with the facility staff conducted a virtual tour of the facility inside and outside. There are 5 clients currently residing in the home. Tour: (11:35AM) The following was observed during the inspection. The facility is a single-family home in a residential neighborhood. There is a family room, dining area, kitchen, 3 bedrooms, 2 bathrooms, group home office, garage, patio and back yard. All areas are appropriately furnished. The facility is clean, safe, and sanitary. There is adequate supply of perishable and non-perishable food. Kitchen utensils, dishes, glasses were found clean adequate and in good condition. There is a refrigerator and freezer in the garage. The facility provides nutritious snacks between meals and the weekly menu is posted by the kitchen area. Medications, first aid kit, all cleaning supplies and laundry detergent, sharp knives, client files are stored and secured out of the reach of clients. The facility license, emergency disaster plan, activity calendar, ombudsman complaint procedure and personal rights were observed to be posted on the wall. The smoke alarm, fire extinguishers and carbon monoxide monitor are in good working condition. There are no bodies of water on the property. The Administrator stated that there are no firearms or any other item that may be considered as weapon in the Facility. Fire/earthquake drills are conducted once a month and kept in a log. There were no physical plant deficiencies noted at the time of this inspection. Report Continues on Next Page At 12: PM LPAs interviewed two staff. A file review was conducted at 1:00PM and included 2 staff files and 2 clients files. There are currently two clients taking medication. Client files contained an original admission agreement. Files for clients currently taking prescribed medication contained all the required documentation such as the medical consent forms and authorizations. Overall, clients are provided adequate services in accordance with their needs and services plan and are being updated. Staff files contained criminal record clearances or exemptions and child abuse index check, job descriptions, required training and work evaluations. All documents were complete and signed by employee. All staff requiring training, including Mandated Reporter, Emergency Intervention, initial and annual training, was current. All adult individuals who require caregiver background checks have received criminal record and child abuse index check clearances or exemption. In accordance with California Code of Regulation, Title 22, Division 6. Exit interview was conducted. A copy of the LIC 809, LIC 809C, LIC 858, and LIC859 were provided to the facility representative.


summary: Facility Evaluation

raw_content:
Narrative:
On 09/27/21 at 10:30AM, Licensing Program Analysts (LPAs) Janeth Chavez and Raymond Wu conducted an unannounced Annual/Required, on site inspection, at the Facility to evaluate compliance with rules and regulations, and to assess the Facility's continuing ability to meet regulatory requirements. The LPAs met with Facility Manager Supervisor, Delphine Luster and stated the purpose for the inspection. Facility Administrator arrived to facility at noon. Upon LPAs arrival there are 5 clients present in the facility. At 11: AM, LPAs along with Staff 1 conducted a walk through of the entire grounds and observed the overall maintenance and operation of the Facility. The Facility is licensed to provide 24-hour services and supervision to male clients ages 12 to 17 and Non-minor dependents. LPAs did not observe any bodies of water. At the time of this inspection, the LPAs observed the clients being supervised by two staff members and the staff appeared to be providing proper care and supervision. At the time of this inspection, the facility physical plant level of maintenance meets regulatory requirements and is in good repair. Passageways are unobstructed. No disinfectants/cleaning materials were accessible to clients. There are plenty non-perishable foods for one week and perishable food for more than two days, and there were plenty meal snacks. The medications are locked and only accessible to staff capable of administering the medications. Facility operates within license conditions and limitations including capacity limitations. The Facility license is posted in a prominent place. The fire extinguisher and smoke alarms including the carbon monoxide monitor are operational. The first aid kit is available and complete. During the inspection process the Administrator provided the following: Staff Training Handbook; Emergency Disaster plan, and facility file indicating emergency drills have been conducted, and their Disaster and Mass Casualty Plan; Facility Sketch and fire escape plan; Planned Activity Schedule; Meals Menu for past three months; Current Personal Rights Listing and reporting requirements; Neighborhood complaint procedures; Biannual review of Emergency Intervention Plan; Monthly Log of Restraints; Medication Log; List of staff certified (in writing) to use or participate in emergency intervention (restraints). At 11:30AM, the LPAs reviewed a random sample of staff/personnel and minor/non-minor dependents records. Client and staff records were complete and up to date. The Administrator provided the Client's Roster, Personnel LIC 500, and staff schedule. All individuals who work at the facility, or have contact with clients, have a current criminal record clearance or exemption, Child Abuse Index Check clearance/Live-Scan fingerprints and/or association. LPAs inspected the facility operational requirements, planned activities, register of clients, safeguards for children/youth's cash allowances, emergency procedures, emergency intervention plan, and emergency intervention staff training, documentation and reporting requirements. The facility staff ratio meets regulatory requirements. The Administrator and staff are fully qualified to perform their assign duties of their individual position. As per administrator, Staff are instructed to report personal rights violations and to provide a safe, healthy and comfortable environment to clients in care. All clients in placement attend school, extracurricular, cultural, and personal enrichment activities. Clients can contact CCLD or Foster Care Ombudsman in confidence without threats, punishment or retaliation. The facility uses a Toyota Sienna as a means for transporting clients to and from school, extracurricular activities and medical appointments. The van seats 7 passengers. The facility maintains a mileage and maintenance log of the vehicle and have current vehicle insurance. LPAs inspected the van and contains all safety fixtures required by law. The Facility Administrator ensures that Title 22 along with the Facility Program Statement, Staff Training Handbook and other Group Home requirements are followed and understood. Also, that reporting requirements are followed and enforced. At the time of this inspection, LPAs observed no specific reason for concern and did not observe hazards, and/or obvious health and safety issues in the Facility premises. At the time of this inspection the Facility is operating within Title 22 requirements. An exit interview was conducted and Copy of this report, Clients Record/Resident's Records Review (LIC 858), Staff Of Staff/Volunteer Records Review (LIC 859) were provided to the Facility Administrator.

visit_type: Annual

met_with: Delphine Luster


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Pamela Silva and Timika Martin on 12/01/22 at 9: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Marcy Madison, Administrator, and inspected the facility inside and out. LPAs reviewed two (2) children's records and two (2) staff personnel files on site at the facility. LPAs reviewed two (2) children's psychotropic medications and medication records. LPAs interviewed two (2) staff on site to discuss the facilities policies and procedures of operation. LPAs were unable to interview children currently prescribed psychotropic medication due to refusal. LPAs provided a copy of this licensing report to Marcy Madison, Administrator. No deficiencies are being cited at this time. LPAs conducted exit interview with the Administrator.

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On November 15, 2023, at 12:57 p.m., Licensing Program Analyst (LPA) John Bonilla arrived at the Stockdale Boys Center, a Short-Term Residential Therapeutic Program (STRTP), for the purpose of conducting an unannounced Case Management inspection regarding a Special Incident Report (SIR) received by the Department on November 6, On November 6, 2023, the Department received an SIR stating that on October 24, a client (C1) (see LIC Confidential Names list dated 11/15/23) had become angry after several incidents that morning led to C1 being shadowed by STRTP Facility Manager (S1). S1 interrupted what was perceived to be a drug purchase when an unknown vehicle approached the facility. C1 stormed into facility, again followed by S1, where C1 began destroying property such as walls and televisions and began making threats of violence against S1, another facility manager present (S2), and the Mental Health Specialist (S3). C1 broke into the facility's office, causing further destruction inside the office, including breaking open the facility's medication cabinet and ingesting prescription pills belonging to self and others. Paramedics were called upon staff observing C1 emptying pill bottles into mouth. Paramedics responded after police arrived, resulting in C1 being taken to hospital. During this inspection, LPA interviewed the three facility staff present on the day of the incident. LPA asked for pertinent documents such as C1's NSP, Staff and Client Roster, the Safety Plan devised for client upon placement, relevant SIRs, and staff training related to de-escalation techniques. No deficiencies were cited during this inspection. A signed copy of this report and LIC811 were provided to Delphine Lester. Exit interview conducted. Further follow-up is required.

met_with: Delphine Lester, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On December 7, 2023, at 11:10 a.m., Licensing Program Analyst (LPA) John Bonilla arrived at the Stockdale Boys Center, a Short-Term Residential Therapeutic Program (STRTP), for the purpose of following up on an unannounced Case Management inspection regarding a Special Incident Report (SIR) received by the Department. LPA met with Delphine Lester, Facility Manager. On November 6, 2023, the Department received an SIR stating that on October 24, a client (C1) (see LIC Confidential Names list dated 11/15/23) had become angry after several incidents that morning led to C1 being shadowed by STRTP Facility Manager (S1). S1 interrupted what was perceived to be a drug purchase when an unknown vehicle approached the facility. C1 stormed into facility, again followed by S1, where C1 began destroying property such as walls and televisions and began making threats of violence against S1, another facility manager present (S2), and the Mental Health Specialist (S3). C1 broke into the facility's office, causing further destruction inside the office, including breaking open the facility's medication cabinet and ingesting prescription pills belonging to self and others. Paramedics were called upon staff observing C1 emptying pill bottles into mouth. Paramedics responded after police arrived, resulting in C1 being taken to hospital. During the inspection, LPA interviewed the three facility staff present on the day of the incident. LPA asked for pertinent documents such as C1's NSP, Staff and Client Roster, the Safety Plan devised for client upon placement, relevant SIRs, and staff training related to de-escalation techniques. LPA also reviewed STRTP's Program Statement. Investigation and confidential interviews revealed that during the incident, STRTP attempted to de-escalate a situation and called law enforcement as per Program Statement procedure, but a manual restraint was not performed due to safety concerning size and weight ratio. . No deficiencies were cited during this inspection. The STRTP was given a Technical Violation and a Technical Advisory. See LIC9102TV and LIC9102TA. A signed copy of this report, LIC9102TV and LIC9102TA were provided to Delphine Lester. Exit interview conducted. Appeal Rights provided. No further action is required.


summary: Facility Evaluation

raw_content:
Narrative:
On December 7, 2023, at 11:10 a.m., Licensing Program Analyst (LPA) John Bonilla arrived at the Stockdale Boys Center, a Short-Term Residential Therapeutic Program (STRTP), for the purpose of conducting an unannounced Case Management inspection. LPA met with Delphine Lester, Facility Manager. During a tour of the facility on November 15, 2023, LPA observed a hallway bathroom for the clients, and three bedrooms for the clients. One of the bedrooms is a "master bedroom" which has its own restroom, only accessible through the bedroom itself. No deficiencies were cited during this inspection. The STRTP was issued a Technical Violation. See LIC9102TV. Exit Interview conducted. A signed copy of this report and LIC9102TV were provided to Delphine Lester. No further action is required. Appeal Rights provided.


facility_name: STOCKDALE BOYS CENTER II

raw_content:
Narrative:
Confidential statements obtained during the investigation were unable to corroborate the allegation as there were no statements obtained to support the allegation. Facility staff denied subjecting any physical abuse to facility clients in care or witnessing a staff or a client choke another facility client at any point in time. Based on the information gathered, the allegation is unsubstantiated as the preponderance of evidence to prove the allegation was not met although the allegation may have happened or is valid. A copy of this report, Confidential Names Form and Appeal Rights were provided to the facility representative. There were no deficiencies cited during this inspection.

Investigation Findings:
13On May 3, 2022 at 10: AM, Licensing Program Analyst (LPA) Joshua Rarela conducted a follow-up complaint inspection to deliver the findings of a complaint investigation concerning the allegation above. LPA Rarela met and discussed the findings with the facility representative named above. During the course of the investigation, LPA interviewed facility staff on 2/11/22 and 2/18/22 and facility clients on 5/3/22 (see Confidential Names Form dated May 3, 2022). LPA also reviewed documents including the placing agency service logs and records, the facility client's Needs and Services Plan, facility incident reports, and facility personnel records. It was alleged that a facility client was choked by an unknown individual. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Joshua Rarela 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: STOCKDALE BOYS CENTER IIFACILITY NUMBER: VISIT DATE: 05/03/2022

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

met_with: Iraina Holliday, Facility Supervisor


raw_content:
Narrative:
The investigation revealed that the facility reported that Ref. #4 and #5 would come to the facility with different bicycles. It revealed that the facility reported that on one occasion Ref. #4 and #5 threw rocks at cars and were chased by a driver while away from the facility without permission. The investigation revealed that the facility reported while Ref. #5 left the facility without permission, Ref. #5 was hit by a train while intoxicated causing a small injury. It revealed that the facility provided first aid, but Ref. #5 refused to go to Urgent Care. A review of the reports indicating law enforcement involvement indicates that the facility followed their Runaway (AWOL) Plan as it relates to Procedures for Responding to a Runaway Youth. The reports indicated that according to the Procedures staff talked to Ref. #5 and offered alternatives, such as accompanying the staff to the park or swimming, instead of leaving without permission. An interview with the Probation Officer (PO) revealed that the PO had no concerns about the facility. The PO indicated that Ref. #5 was a chronic runaway, and constantly used drugs and alcohol. Interviews with the other witnesses and Ref. #5, revealed that Ref. #5 was intoxicated by liquor or high on drugs on more than one occasion. It revealed that when staff attempted to engage Ref. #5 or confiscate liquor bottles in Ref. #5's possession, Ref. #5 would leave without permission. The investigation revealed that the facility provided Ref. # Core Services and Trauma-Informed Care Services with their mental health personnel, but Ref. #5 would not engage with the therapists. The investigation revealed that on one occasion the facility requested that the Probation Department search Ref. #5's physical person, but nothing was found. It revealed that on one occasion staff searched Ref. #5's bedroom and found one empty liquor bottle. The LPA was unable to corroborate the allegations. Based upon the above, it is determined that there is no preponderance of evidence to substantiate that the facility did not properly supervise Ref. #5; did not prevent Ref. #5 from bringing alcohol into the facility; nor report incidents that occur at the facility to the appropriate parties. So, although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the allegations are unsubstantiated. There are no deficiencies to be cited regarding this complaint. A copy of this report was emailed to the facility representative.

Investigation Findings:
On December 15, 2022 at 12:45 p.m., Licensing Program Analyst (LPA), Karen McGee, delivered the findings of the complaint investigation to the facility. The LPA met with Administrator, Marci Madison. On August 22, 2022, the Monterey Park Children's Residential Program (MPCRP), received a complaint with the above-mentioned allegations. Confidential interviews were conducted that included, but were not limited to: four staff - one staff, Ref. #1 on August 26, 2022, the Administrator on December 6, 2022 and two staff, Ref. #2 and #3 on December 14, 2022 via telephone; two clients, Ref. #4, on December 8, 2022 and Ref. #5 on December 14, 2022 face-to-face; and one Probation Officer via telephone on December 12, 2022. The LPA reviewed Special Incident Reports and Ref. #5's Needs and Services Plan. Following is the evidence that was revealed in the investigation: The investigation revealed that Ref. #5 was placed at the facility from July 28, 2022 and discharged on August 16, 2022, which indicates that the client resided at the facility for 20 days. A review of records indicates that the facility submitted incident reports to MPCRP involving Ref. #5 on the following dates: 7/29/22, 7/31/22, 8/4/22, 8/5/22, two on 8/6/22, two on 8/7/22, and 8/12/22, as required by Title Regulations, Reporting Requirements. The LPA observed incident reports for the incidents that were stated to have not been reported (cont'd). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Karen McGee LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: STOCKDALE BOYS CENTER IIFACILITY NUMBER: VISIT DATE: 12/15/2022

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

met_with: Marci Madison


raw_content:
Narrative:
The facility provides wi-fi to clients. However, the clients need to earn their privilege to use wi-fi. The clients have to be in level three and attend school in order for them to use the wi-fi. The wi-fi is turned off at PM to prevent the clients to be up all night using their devices connected to the internet. Staff do not turn off the wi-fi as discipline. Statements obtained from the confidential interviews did not provide sufficient information to corroborate the allegations. Based on the information gathered, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that alleged violation occurred, therefore the allegation is unsubstantiated. There were no deficiencies cited during this inspection. An exit interview was conducted. Appeal rights explained and a copy of this report, and Appeal Rights were provided to the facility representative.

Investigation Findings:
13On April 26, 2023, at 11: AM, Licensing Program Analyst (LPA) Karen Suh conducted a follow-up complaint inspection to deliver the findings of an investigation concerning to the allegations above. The LPA met with the representative named above and discussed the findings. The investigation included confidential interviews that consisted of but were not limited to: Administrator and three staff on April 14, 2022; one client on December 27, 2022. The LPA was unable to interview the C1 as they refused to be interviewed. The LPA was unable to contact the County Social Worker (CSW) after several attempts. The LPA reviewed C1's Daily Logs for August 2022, Needs and Services Plan and Personnel Record. It was alleged that a staff threatened to fight client and staff turn off wi-fi at the facility as discipline. Staff denied the allegations stating that they did not threaten the client to fight; staff never threatened any clients to fight. Staff are trained and received trainings in personal rights; staff are trained to manage situations. Staff do not fight with clients. (cont'd) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Karen Suh 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: STOCKDALE BOYS CENTER IIFACILITY NUMBER: VISIT DATE: 04/26/2023

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

met_with: Iraina Holliday, Facility Manager Supervisor


raw_content:
Narrative:
When staff become aware of clients using or smoking marijuana in the facility either by observance or smell, staff request the clients to surrender the contraband. in the facility when staff a. Clients are informed house rules of drugs during intake process. It was alleged that staff do not notify authorized representative of doctors appointments and staff are not returning authorized representatives calls in a timely manner. Staff denied the allegations. Staff stated social workers or authorized representatives, are provided with clients' medical appointment dates when they inquire. A copy of examinations and reports are provided to social workers or authorized representatives after services are completed. Staff stated call are always returned as soon as possible. The call is returned immediately or next business day if there is a voicemail left. However, social workers or authorized representatives have Administrator and facility manager supervisor's cell phone number to contact if they need to contact someone immediately. It was also alleged that staff are not ensuring minor attends school. Staff denied the allegation. Staff encourage clients to attend school. Staff stated since staff cannot force clients to go to school if they refuse, clients are provided incentives of $5.00 a day when they go to school. The LPA was unable to obtain any statements from clients as they declined to be interviewed. The statements obtained from the confidential interviews did not provide sufficient information to corroborate the allegations. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that alleged violations occurred, therefore the allegations are unsubstantiated. There were no deficiencies cited during this inspection. An exit interview was conducted. Appeal rights explained and a copy of this report, and Appeal Rights were provided to the facility representative.

Investigation Findings:
13On November 15, 2024, at 9: AM, Licensing Program Analyst (LPA), Karen Suh, conducted a follow-up complaint inspection to the facility above to deliver the findings of a complaint investigation. LPA met with the representative named above and discussed the findings. The investigation included confidential interviews that consisted of but were not limited to: Head of Services, four staff on May 5, 2024, and rehabilitation specialist on September 25, 2024. The LPA was unable to interview three clients (see Confidential Names LIC 811, dated November 15, 2024) as they declined to be interviewed. The LPA reviewed House Rules of substance use, school, and the plan of operations regards to medical/dental services. It was alleged minors are using illegal substances in the facility. Staff stated clients are not allowed to smoke or have possession of any drugs in the facility. Staff encourage clients not to smoke marijuana and remind them about dangers and long-term effects of substance use. (cont.) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Karen Suh 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: STOCKDALE BOYS CENTER IIFACILITY NUMBER: VISIT DATE: 11/15/2024


raw_content:
Narrative:
On January 9, 2025, as C1 was preparing for school, he was walking around with his phone, speaking softly to himself. At that moment, he encountered S1 and S3, informing them that they had been sexually assaulted earlier that morning while they were asleep. C1 was unable to provide any information regarding the alleged assailant and declined medical assistance. S1 reported that the Bakersfield Police had been informed, and soon after, Officer Nelson arrived at the STRTP to converse with C1; however, the information given by C1 was inconsistent, as C1 claimed that the sexual assault had been happening for the last eight months yet had only been living in the STRTP for two weeks. Because C1 provided conflicting details and declined to pursue medical assistance, Officer Nelson consulted with the staff and then left the STRTP. The staff members (S1, S2, and S3) refuted the allegation, asserting that all personnel are trained in trauma-informed care and recognize the significance of upholding a secure and healthy atmosphere for every client. S3 stated that on the night of the alleged incident, they were the only staff member on duty. They described the night as calm and confirmed that no one entered or exited the facility during that time. S3 expressed surprise at what C1 had reported the following morning. S2, the Head of Service, indicated that they have tried to arrange meetings with C1 three to four times weekly; however, C1 often rejected these meeting requests. Furthermore, S2 mentioned that they provided both individual and group therapy sessions and had enrolled C1 in a substance abuse program, due to C1's history of substance abuse, yet C1 has declined to participate in these sessions. S2 also disclosed that C1 frequently suffered from hallucinations triggered by this substance use, which intensified as C1 increasingly went AWOL. Information gathered from the PO indicated that C1 has a background of substance abuse and may exhibit delusional behavior at times. Before C1's absence without leave from the STRTP on January 21, 2025, they had made allegations of sexual abuse. These allegations were communicated to the relevant authorities, and C1 was referred for a medical evaluation at Urgent Care, where no irregularities were detected. Additionally, confidential statements obtained from facility clients refuted the allegation, asserting that they have never witnessed or heard of any staff behaving inappropriately with clients and that they are consistently monitored by staff. Clients also reported having access to mental health services and programs, and stated that they have no concerns regarding the care and supervision they receive. Therefore, based on the information received, the above allegation(s) are determined to be unsubstantiated. Although the allegation(s) may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred, therefore, the allegation(s) are found to be unsubstantiated. Appeal Rights were provided and discussed with the STRTP Facility Manager. There are no deficiencies to be cited at this time. An exit interview was conducted, and a copy of the report along with the (LIC 811) was left with the STRTP Facility Manager.

Investigation Findings:
13On June 19, 2025, at 11: AM, Licensing Program Analyst (LPA) John Bonilla on behalf of LPA Winston Moroney carried out an unannounced inspection of the aforementioned Short Term Residential Therapeutic Program (STRTP) to present the findings related to the stated complaint. LPA engaged with the Facility Manager of the STRTP and reviewed the results concerning the identified allegation(s). On January 9, 2025, the California Department of Social Services Community Care Licensing Division received a complaint from Centralized Complaint and Information Bureau (CCIB) with the following allegation(s): Minor was sexually assaulted UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: John Bonilla 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 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: STOCKDALE BOYS CENTER IIFACILITY NUMBER: VISIT DATE: 06/19/2025

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

met_with: Kiauna Dixon, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 10/26/2020 at 2: PM, Licensing Program Analyst (LPA) Janeth Chavez conducted a post-licensing virtual inspection of the Short Term Residential Therapeutic Program (STRTP) and met with the Administrator Marcy Madison. The LPA along with the facility staff conducted a virtual tour of the facility inside and outside. There are 5 clients currently residing in the home. At 2:35PM the following was observed during the virtual inspection. The facility is a single-family home in a residential neighborhood. The facility consists of 4 bedrooms (one of which is being utilized as an office), 2 bathrooms, living room, game room, kitchen, dining room, laundry, 2-car garage, covered patio and backyard. All areas are appropriately furnished. The facility is clean, safe, and sanitary. There is adequate supply of perishable and non-perishable food. Kitchen utensils, dishes, glasses were found clean adequate and in good condition. There is a refrigerator and freezer in the garage. The facility provides nutritious snacks between meals and the weekly menu is posted by the kitchen area. Medications, first aid kit, all cleaning supplies and laundry detergent, sharp knives, client files are stored and secured out of the reach of clients. The facility license, emergency disaster plan, activity calendar, ombudsman complaint procedure and personal rights were observed to be posted on the wall. The smoke alarm, fire extinguishers and carbon monoxide monitor are in good working condition. There are no bodies of water on the property. The Administrator stated that there are no firearms or any other item that may be considered as weapon in the Facility. Fire/earthquake drills are conducted once a month and kept in a log. There were no physical plant deficiencies noted at the time of this inspection. Report Continues on Next Page At 02: PM LPA interviewed two staff. A file review was conducted at 3:30PM and included 2 staff files and 2 clients files. There is currently one client taking medication. Client files contained an original admission agreement. Files for clients currently taking prescribed medication contained all the required documentation such as the medical consent forms and authorizations. Overall, clients are provided adequate services in accordance with their needs and services plan and are being updated. Staff files contained criminal record clearances or exemptions and child abuse index check, job descriptions, required training and work evaluations. All documents were complete and signed by employee. All staff requiring training, including Mandated Reporter, Emergency Intervention, initial and annual training, was current. All adult individuals who require caregiver background checks have received criminal record and child abuse index check clearances or exemption. In accordance with California Code of Regulation, Title 22, Division 6. Exit interview was conducted. A copy of the LIC 809, LIC 809C, LIC 858, and LIC859 were provided to the facility representative.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Janeth Chavez conducted a case management virtual inspection for the purpose of addressing an Exemption Denial for Ref-1 received on 10/05/2020. LPA reviewed with Administrator the Exemption Denial letter stating that the request for a criminal record exemption for Ref- ID # 7512118225 has been denied. A denied exemption means that this individual may not work or be present in a facility licensed by the Department. This individual is also prohibited from having contact with clients of any facility licensed by the Department. If this individual was allowed to work or be present in your facility because he/she had a previous clearance, this individual must be immediately removed from your facility. Per Administrator, subject individual was a previous employee of the facility during the exemption process. However, the subject individual is no longer employed at this facility as of 10/12/2020. Administrator provided a signed copy of the Confirmation of Removal (LIC 300B) for Ref-1 signed and dated 10/12/2020. LPA interviewed Staff 1 & 2 and both staff stated that Ref-1 is no longer employed at this facility since 10/12/2020. Exit interview was conducted and a copy of LIC 809 & LIC 811 was provided to the facility representative.

met_with: Marcheletta Madison, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 09/08/21 at 12:27PM, Licensing Program Analysts (LPAs) Janeth Chavez and Raymond Wu conducted an unannounced Annual/Required, onsite inspection, at the Facility to evaluate compliance with rules and regulations, and to assess the Facility's continuing ability to meet regulatory requirements. The LPAs met with Facility Manager Supervisor, Iraina Holiday and stated the purpose for the inspection. The Facility Administrator was not present during the inspection. At 12:40PM, LPAs along with Staff 1 conducted a walk through of the entire grounds and observed the overall maintenance and operation of the Facility. The Facility is licensed to provide 24-hour services and supervision to male clients ages 12 to 17 and non minor dependents. LPAs did not observe any bodies of water. At the time of this inspection, the LPAs observed the clients being supervised by two staff members and the staff appeared to be providing proper care and supervision. At the time of this inspection, the facility physical plant level of maintenance meets regulatory requirements and is in good repair. Passageways are unobstructed. No disinfectants/cleaning materials were accessible to clients. There are plenty non-perishable foods for one week and perishable food for more than two days, and there were plenty meal snacks. The medications are locked and only accessible to staff capable of administering the medications. Facility operates within license conditions and limitations including capacity limitations. The Facility license is posted in a prominent place. The fire extinguisher and smoke alarms including the carbon monoxide monitor are operational. The first aid kit is available and complete. An exit interview was conducted and Copy of this report was provided to the Facility Manager. An Annual Continuation will be conducted to complete the inspection tool and review clients and staff files. The are no deficiencies cited on today's inspection.

met_with: Iraina Holiday


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Ashley Ruacho and Timika Martin on 05/18/26 at 9: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Supervising Facility Manager, Iraina Holiday, and inspected the facility inside and out. There are no clients at this facility eligible for inspection due to the client prescribed psychotropic medication being placed in the facility for less than 30 days. LPAs reviewed 0 child record and 3 of staff personnel files on site at the facility. LPAs reviewed 0 child psychotropic medications and medication records. LPAs interviewed 2 of staff on site to discuss the facility's policies and procedures of operation. LPA provided a copy of this licensing report to Supervising Facility Manager, Iraina Holiday. No deficiencies are being cited at this time. LPA Ruacho conducted exit interview with Supervising Facility Manager, Iraina Holiday.

met_with: Iraina Holiday - Facility Manager


facility_name: ST. ANNE'S MATERNITY HOME

raw_content:
Narrative:
Food Service: LPA Martin's observations of facility's dinning and kitchen areas including, but not limited to, food storage, preparation, menus, and temperature controls of refrigerator and freezer storage produced no damaged containers, expired or food spoilage during this investigation period. Food was observed stored, prepared and served free from contamination and spoilage. Accommodations are made for those with special diets and/or allergies. Food quantities are observed ample for facility capacity. Interviews revealed that Clients believe that the food overall is "okay" but, believes the food could be seasoned better. Neglect/Lack of Supervision: A review of client file/records revealed Client #1 (C1) was first placed in the facility on 05/13/2020. At the beginning of placement through current date, the facility has and continues to provide C1 with Spanish translator/interpreter on demand for client's communication needs. C1 disclosed no concerns with the need for Spanish interpreter while in placement. LPA confirmed facility currently has assigned Spanish interpreters employed on each shift. There is at least one Spanish speaking Therapist available for Client's needs. Records reviewed revealed Client #2 (C2) was first placed in the facility on 05/15/2020 through 02/16/2021. During that stint of time C2 left the facility without permission(AWOL) on numerous occasions. A review of records and interviews indicate facility followed appropriate procedures including reporting appropriate parties for each occurrence. Records further indicates suitable measures were taken by facility to address C2's needs including, but not limited to, mental health services and the acknowledgment of the eventual need for a more appropriate placement to meet C2's need for a higher level of care. C2 was not interviewed after unsuccessful attempts during the investigation process due to AWOL status. Although the above allegations may have happened or is valid, there is not a preponderance of evidence to prove that a violation occurred. Based on the gathered evidence the allegations of neglect/ lack of supervision and food service is Unsubstantiated. There were no deficiencies cited per California Code of Regulations, Title 22. Exit interview was conducted; a copy of appeals rights and this report was emailed to Mr. Weaver.

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

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

met_with: Tony Weaver Vice President of Housing Programs


raw_content:
Narrative:
Evidence obtained revealed that Staff did intervene to prevent and stop altercation between residents. Staff immediately secured residents infant safely away from the altercation. Also, confidential interviews with Child 1 & Child 2 reveal during altercation food was thrown, hitting and biting due to Child 1 put Child 2 in headlock. Child 2 bite Child 1 to get released from headlock. Staff revealed all steps were taken to de escalate the residents prior to altercation and continued during altercation.. Child 2 admitted throwing food due to mad at Child 1 for smart comments. Also staff are providing healthy foods for resident and adequate personal products are available for resident use. Based on the gathered evidence the allegations are Unsubstantiated. There were no deficiencies cited per California Code of Regulations, Title 22. Exit interview was conducted; a copy of appeals rights and this report was emailed to Mr. Weaver

Investigation Findings:
13On January 6, 2022 at 10:12AM PM Licensing Program Analyst (LPA), Zena Phillips conducted a follow-up complaint investigation visit to ST. ANNE'S STRTP and met with Tony Weaver, Vice President of Housing Programs. The purpose of the visit was to deliver findings for the above complaint allegations. During the course of investigating the allegations: LPA Phillips conducted confidential interviews with related parties, reviewed facility records and Incident Reports. Based on the interviews conducted and statements obtained during the investigation the above allegations cannot be substantiated because LPA Phillips obtained inconsistent statements from staff and residents in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Zena Phillips LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290b El Segundo, CA Facility Name: St. ANNE'S STRTPFACILITY NUMBER: VISIT DATE: 01/06/2022

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