summary: Facility Evaluation

raw_content:
Narrative:
On June 18, 2024, at 1:15p.m., Licensing Program Analyst (LPA) Val Wilson, Licensing Program Manager (LPM) Jennifer Smith, and Regional Manager (RM) LaCresha Cook met with Family Assistance Program (FAP) Chief Executive Officer (CEO) Darryl Evey, Director of Youth Shelters (DYS) Sylvia Steinhart, Our House Administrator Joe Mendoza, Our Stay Administrator Fatima Herrera, and My Place Shelter Manager Nike Hanson via Microsoft Teams for a virtual informal office conference. The purpose of the meeting was to discuss the following issues and concerns with the Licensee for Our House, My Place, and Our Stay facilities: On site showers for Department of Children and Family Services (DCFS) clients not currently placed at a facility, reporting requirements, and accountability. DCFS Showers- The CEO discussed that there is a process, but it is not in the program statement or plan of operation. Youth are provided the opportunity under the supervision of a county social worker (CSW) to shower at Our House, My Place, and Our Stay in hopes they will feel comfortable and more relaxed at the facility and choose to stay at the facility instead of return to the DCFS office. If the youth do not want to remain at the facility, they can return to DCFS with the CSW until a placement can be identified. The CEO noted FAP has been providing this service for the past 3 years. LPM inquired as to whether the CSW staff monitoring the DCFS client showers for clients not currently placed at the facility were fingerprint cleared and associated to the facility. FAP has not identified if the CSWs have been fingerprinted and/or associated with each facility. The CEO commented that this is a common practice with shelter facilities across the State and that legislation needs to be reviewed if the fingerprinting of CSWs and Department of Behavioral Health staff providing services at the facility is a requirement. The CEO also requested for the fingerprint issue to be elevated for follow up regarding if fingerprinting and clearance requirements would also apply to all CSW and Department of Behavioral Health (DBH) staff that provide services at each facility. RM agreed to provide clarification. The CEO noted that if the CSWs providing services in the facility is the (Continued on page 2) Pg 2 (Continued from page 1) primary concern, a possible plan of correction would be to complete intake procedures for the DCFS clients and then complete exit procedures for each client that decides not to stay in placement after showering. The CEO also confirmed there are no non-minor dependents brought to the facilities for showers. Reporting Requirements and Accountability- LPM Smith noted on the Board of Director (BOD) Meeting Minutes dated January 30, 2024, the CEO was "reinstated"; However, CCL was never notified the CEO was removed and who the contact was in the CEO's absence. The CEO shared that the minutes documented the incident incorrectly. The CEO revealed this was a BOD discussion and the CEO was asked to work at a different location until a human resources concern was resolved, but the CEO did not change. LPM Smith also inquired into a former board member revealing to CCL they received some correspondence for the BOD's when they had not served on the BOD's for several weeks. LPA received the updated LIC Administrative Organization for each facility and will email the LIC Board of Director Governing Body Statement to the DYS to secure a set of signed and updated BOD statements for all three facilities. The CEO questioned and the LPA confirmed that each time there is a change in the BOD a new LIC 309 will need to be provided for each facility. Additionally, each new BOD member must sign a LIC 9165 for each facility. LPM opened up discussion and the CEO inquired into the application for Our Place. LPM and RM assured the CEO that the assigned LPA would be contacting FAP the week of June 24, 2024, to schedule Component 3. The licensee is being requested to submit a Plan of Correction for each of the following by July 1, 2024: - How will FAP ensure regulatory compliance for DCFS showers occurring in the licensed facilities? - Provide an addendum to the program statement with FAP DCFS shower plan. - How will FAP ensure reporting requirement notifications are updated to CCL in a timely manner? - Updated LIC9165 will be provided to LPA. The Plan of Action response will be submitted to CCL by July 1, 2024. If more time is needed to submit the plan of action or there are any questions, please contact LPA Valerie Wilson at valerie.wilson@dss.ca.gov or (951) 897-9155. A copy of this report was emailed to DYS Sylvia Steinhart for electronic signature. The signed report will be placed in the facility file.


state: CA

facility_name: OUR STAY

summary: Facility Evaluation

raw_content:
Narrative:
On June 25, 2024, at 11: AM, Licensing Program Analysts (LPAs) Val Wilson and Jason Dalton, arrived at Our Stay Youth Homelessness Prevention Center (YHPC) for an unannounced post-licensing inspection. LPA was notified the first placement was on April 23, 2024. LPA's were met at the facility by Administrator Fatima Herrera and Director of Youth Shelters, Sylvia Steinhart. The LPA's toured the inside and outside of the facility with the Administrator. LPA's observed that the Facility Sketch, Emergency Disaster Plan (LIC 610), Personal Rights, Grievance procedures, and Visitation policies were posted in the living room. LPA's also observed only one posted grievance form. There were no additional forms or a confidential drop area for clients to use without going in to the staff office. Living room is furnished with couches and has tabletop activities. LPA's observed Wi-Fi and a wireless telephone on its charging base in the living room. The clients are provided the Wi-Fi pass code during intake. Wi-Fi is available 24 hours a day. The kitchen has a sink and refrigerator with perishable food. The cabinets have nonperishable food and a weekly menu is posted. The daily activities schedule and the monthly community activities are also posted in the kitchen area. -Bedroom #1- has two single beds. The beds had linen, comforters, and pillows. The room was furnished with two beds and a dresser. It will sleep two clients. -Bedroom #2- has two single beds. The beds had linen, comforters, and pillows. The room was furnished with two beds and a dresser. It will sleep two clients. -Bedroom #3- has two single beds. The beds had linen, comforters, and pillows. The room was furnished with two beds and a dresser. It will sleep two clients. Bedrooms were arranged so that no more than two clients share a room, and there is one client per bed. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to ***CONTINUED*** ***Continued** another room. There were adequate drawer and closet space for client's belongings. Bedroom #4 is an office space- This room is for staff and the closet is used for storage, medications, and sharp objects. The first aid kit is kept in the staff office and contains all required supplies. Additionally, there is a fully supplied first aid kit kept in the facility vehicle. All hazardous items are stored in bedroom 4/staff office. The medications and confidential files are locked and stored in the staff office. Electronic client files can be accessed through an application called Apricot. Cleansers/chemicals were removed from the medication closet and will be locked and stored in the staff office. A binder is kept in the staff office with inspection copies to be inclusive of three years. There are no guns or weapons as stated by Administrator. Telephone, and address of the physician is not available for client 1, client 2, and client 4 on the LIC 9020. Water temperature in restroom #1 shower is 114 degrees Fahrenheit and the sink is 120 degrees. Restroom #2 sink is 116 degrees Fahrenheit and the bathtub is 116 degrees Fahrenheit. The kitchen trash was observed to have a lid. Clean linens are currently stored in the staff office, which requires a staff to access. . Fire alarm system is synchronized and working properly. The garage was separated from the house with an external door and is utilized for storage only. There are no emergency nonperishable supplies maintained at this time. LPA's observed a fenced off inaccessible area behind the facility in the backyard. The backyard where clients have access to play is completely fenced and free of weeds, dirt, and residue around the house. There is no pool or other bodies of water. LPA's observed safe, clean, and age-appropriate educational supplies and games for the age group of clients to be cared for both inside and outside the facility. Fire clearance was received on 07/26/23. The LIC 999 facility sketch will need updating for page 1- two carbon monoxide detectors, and page 2- the yard sketch. Based on LPA observation, record review, and interviews, the facility is issued a Type B: Physical Plant 84576(e)(4). Additionally, the facility is issued Technical Assistance for Physical Plant 84572.2(b), 84587.2(b)(1), and 84088(c)(2). Lastly, the facility is issued Technical Assistance for Operational Requirements 84571(b)(2). An exit interview was conducted. A copy of this report, LIC 811, 809D, LIC 9102's, and appeal rights were provided and explained to the Administrator

report_type: Facility Evaluation

met_with: Fatima Herrera


summary: Facility Evaluation

raw_content:
Narrative:
On July 19, 2024 at 9: AM, Licensing Program Analysts (LPAs), Jason Dalton and Val Wilson, arrived unannounced at Our Stay Youth Homelessness Prevention Center to complete a post licensing inspection initiated on June 25, 2024. LPAs previously completed Physical Plant and Operational requirements. During today's inspection, LPA's completed Staff Interviews, Client Interviews, Facility Contact Information, Disaster Preparedness, and the Emergency Intervention Plan. LPAs were met at the facility by the Director of Youth Shelters, Sylvia Steinhart, and the Administrator, Fatima Herrera. There were two staff members (staff 5 and staff 6), the Administrator (staff 2), Director of Youth Shelters (staff 1), and six clients (client 6, client 7, client 8, client 9, client 10 and client 11 ) present at the time of the inspection. Appropriate staff/client ratios were verified during the inspection. At 10: AM LPA's toured the front and side yard with staff 2. LPA's observed six piles of feces on the lawn, firework debris, and a cigarette butt. The feces, firework debris, and cigarette butt were immediately removed by staff 6. LPAs conducted five staff (staff 1, staff 2, staff 3, staff 4, and staff 5) and five client interviews (client 1, client 2, client 3, client 4, and client 5). The clients indicated that their basic needs are being met at the facility and core services being provided as well. The staff interviews stated there were no issues or concerns. Fire drills were requested at 10: AM and were not received. Staff 2 was able to provide a log and a blank form, but not the fire drills. The Disaster and Mass Casualty plan identifies the location of the utility shutoff valves; However, there are no instructions for use. There is no provision of emergency power or identification of suppliers of a backup generator. There is no permanently installed generator or portable generator available for the facility at this time. The storage and preservation of medications, including the storage of medications that require refrigeration are not discussed in the Disaster and Mass Casualty Plan. The Administrator was unable to provide copies of facility staff training plans to each staff member upon hire. The Administrator was unable to provide copies of the current staff training that include staff responsibilities during an emergency or disaster. An appraisal for each individual served by the facility was requested at 1: PM. The documents were not readily available in completion. ****** ***continued from previous page*** Documents were provided at 2: PM. Contact information for the responsible party and physician for each individual served by the facility is kept on the LIC 9020. A set of keys is available in the medication closet for use during an evacuation that provides access to all areas of the facility (doors and files); However, the car keys are not available on the emergency set of keys kept for use during an evacuation. Staff 2 was unable to provide a written record of the Emergency Intervention staff training for staff 1, staff 2, staff 3, staff 4, and staff 5. Staff 2 was not able to provided a name and training certificate of the Emergency Intervention Staff Training instructor who provided the training. This was confirmed by staff 1. Staff 2 was unable to provide a certification from the instructor that staff 1, staff 2, staff 3, staff 4, and staff 5 have successfully completed the competency test for the Emergency Intervention Plan. Based on LPA observation, record review, and interviews, the facility is issued Type B violations for: Disaster Preparedness - 1565(b) - Disaster Preparedness - 1565(a)(7)(A) - Disaster Preparedness - 80023(d)(2) - Emergency Intervention Plan 84365(d)(1)(C) - Emergency Intervention Plan 84365(d)(1)(A) - Additionally, the facility is issued Technical Violation for:Emergency Intervention Plan - 84365(d)(1)(B) - Disaster Preparedness - 1565(f)(2)(B) - Disaster Preparedness - 1565(a)(7)(E) - Disaster Preparedness - 1565(a)(6) - An exit interview was conducted. A copy of this report, LIC 811, 809, 809C, 809D, LIC 9102's, and appeal rights were provided and explained to the Administrator, Fatima Herrera. LPA's will return at a later date to complete the inspection.

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On July 30, 2024 at 10: AM, Licensing Program Analysts (LPAs), Jason Dalton and Val Wilson, arrived unannounced at Our Stay Youth Homelessness Prevention Center to complete a post licensing inspection initiated on June 25, 2024. LPAs previously completed Physical Plant, Operational requirements, Staff Interviews, Client Interviews, Facility Contact Information, Disaster Preparedness, and the Emergency Intervention Plan. During today's inspection, LPA's completed review of five staff files and five client files. LPAs were met at the facility by Youth Advocate, Davena Harris (S5- staff 5). The Administrator, Fatima Herrera (S2- staff 2), arrived a 11: AM. There were two staff members (staff 5 and S7- staff 7) and two clients (C12- client 12 and C13- client 13 ) present at the time of the inspection and appropriate staff/client ratios were verified. LPA's requested the client roster and the staff roster. The client records were reviewed for client 1 (C1), client 2 (C2), client 3 (C3), client 4 (C4), and client 5 (C5) and there were no deficiencies cited. The staffing records were reviewed for staff 1 (S1), S2, staff 3 (S3), staff 4 (S4) and S5 and the following was observed and reviewed with the Administrator (S2): This facility utilizes the Community Crisis Response Team (CCRT) for mental health related crisis. A binder is kept in the staff office of available community services and resources in addition to posters placed in the living room area. S3 and S4 staff files do not have the duties of the employee. Staffing records for S3, S4 and S5 did not verify successful completion of job shadowing by a statement completed by the experienced facility personnel being shadowed affirming: a) specific activity observed; b) dates and times of shadowing; and, c) training topic listed in Section 84065(i)(3)(A) through (R) that is satisfied by the job shadowing activity. Facility's program and services training, including program philosophy, activities and community resources was missing from staff files for S1, S2, S3, S4, and S5. Staff files for S1, S2, and S3 were missing verification of training for facility's policies and procedures, including reporting requirements to the Department. S1, S2, S5 were missing verification of mandated child abuse reporter training. S1, S2, S3, S4, and ***Continued*** ***Continued*** S5 files did not verify completion of training for medication procedures, assistance with medication, universal precautions, recognition of early signs of illness and the need for professional assistance, and other health related issues, including oversight and monitoring of psychotropic medications for children in foster care and related topics specified in Section 16501.4(d) of the Welfare and Institutions Code. S5 did not have verified training in the staff file for facility manager training. Verifiable training for child's rights as specified in Welfare and Institutions Code section 16001.9 and Section 84072, including a child's right to have fair and equal access to all available services, placement, care, treatment, and benefits, and to not be subjected to discrimination or harassment on the basis of actual or perceived race, ethnic group identification, ancestry, national origin, color, religion, sex, sexual orientation, gender identity, mental or physical disability, or HIV status was not available in the staff files for S4. Documentation of successful completion of training was not maintained consistently in the personnel record for each child care staff. Based on LPA observation, record review, and interviews, the facility is issued Type B violations for Staffing Records 84065(i)(3)(M), 84065(i)(3)(B), 84065(i)(1)(C)(4), 80066(a)(8), and 84065(i)(3)(C). Additionally, the facility is issued Technical Violation for Staffing Records 84065(d)(3) and Technical Assistance for Staffing Records - 84065(i)(3)(S), and 84065(i)(5). An exit interview was conducted. A copy of this report, LIC 811, 809, 809C, 809D's, LIC 9102's, and appeal rights were provided and explained to the Administrator, Fatima Herrera, with the Director of Youth Shelter's, Sylvia Steinhart on the phone.


summary: Facility Evaluation

raw_content:
Narrative:
On March 7, 2025, at 10: AM, Licensing Program Analyst (LPA) Val Wilson, arrived at Our Stay Youth Homelessness Prevention Center (YHPC) for an unannounced annual licensing inspection. LPA met with interim Administrator (ADM), Joseph Mendoza and Director of Youth Shelters (DYS), Sylvia Steinhart at the facility. During the inspection there were no client admissions or youth present. Staff present were the ADM, DYS, and Staff 3 (S3). The LPA toured the inside and outside of the facility with the Administrator. LPA observed that the Facility Sketch, Emergency Disaster Plan (LIC 610), Personal Rights, Grievance procedures, and Visitation policies were posted in the living room. LPA also observed posted grievance forms and a confidential grievance drop box. Living room is furnished with couches and has tabletop activities. LPA observed Wi-Fi and a wireless telephone on its charging base in the living room. The clients are provided the Wi-Fi pass code during intake. Wi-Fi is available 24 hours a day. The kitchen has a sink and refrigerator with perishable food. The cabinets have nonperishable food and a weekly menu is posted. The daily activities schedule and the monthly community activities are also posted in the kitchen area. -Bedroom #1- has two single beds. The beds had linen, comforters, and pillows. The room is furnished with two beds and a dresser. It will sleep two clients. -Bedroom #2- has two single beds. The beds had linen, comforters, and pillows. The room is furnished with two beds and a dresser. It will sleep two clients. -Bedroom #3- has two single beds. The beds had linen, comforters, and pillows. The room is furnished with two beds and a dresser. It will sleep two clients. ***continued on page 2*** ***Continued from page 1*** Bedrooms were arranged so that no more than two clients share a room, and there is one client per bed. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There were adequate drawer and closet space for client's belongings. Bedroom #4 is an office space- This room is for staff and the closet is used for storage, medications, and sharp objects. The first aid kit is kept in the staff office and contains all required supplies. Additionally, there is a fully supplied first aid kit kept in the facility vehicle. All hazardous items are stored in bedroom 4/staff office. The medications and confidential files are locked and stored in the staff office. Electronic client files can be accessed through an application called CAP60. A binder is kept in the staff office with inspection copies to be inclusive of three years. There are no guns or weapons as stated by Administrator. Fire drills were provided for 2024 and the first quarter of 2025. The Disaster and Mass Casualty plan and the Emergency Disaster plan were posted and accessible in the staff office. The garage has the emergency power backup generator. The storage and preservation of medications, including the storage of medications that require refrigeration, is locked and located in the staff office. Water temperature in bathroom #2 is 115 degrees Fahrenheit and the kitchen sink water temperature is 115.7 degrees Fahrenheit. The kitchen trash was observed to have a lid. Clean linens are stored and accessible in laundry area. Fire alarm system is synchronized and working properly. The carbon monoxide detector is in the hallway and works properly. The garage was separated from the house with an external door and is utilized for storage only. The emergency nonperishable supplies are maintained in the staff office. LPA observed a fenced off inaccessible area behind the facility in the backyard. The backyard where clients have access to play is completely ***continued on page 3*** ***continued from page 2*** fenced and free of weeds, dirt, and residue around the house. There is no pool or other bodies of water. LPA observed safe, clean, and age-appropriate educational supplies and games for the age group of clients to be cared for both inside and outside the facility. This facility utilizes the Community Crisis Response Team (CCRT) for mental health related crisis. A binder is kept in the staff office of available community services and resources in addition to posters placed in the living room area. LPA completed review of five staff files and zero client files. The staffing records were reviewed for staff 1 (S1), staff 2 (S2), staff 3 (S3), staff 4 (S4) and staff 5 (S5) and were in regulatory compliance. Interviews were conducted with S1, S2 and S3. Regarding accountability, LPA reviewed the December Board Meeting minutes that did not reflect discussion of documents reviewed by the Board during the previous quarter. The DYS provided evidence they are in the process of bringing the Minutes into compliance by March 14, 2025. Based on LPA observation, record review, and interviews, the facility is issued a Technical Violation for Accountability 84063(a)(9) An exit interview was conducted. A copy of this report, LIC 811, LIC 809, LIC 809C's, LIC 9102., and appeal rights were provided and explained to the interim Administrator, Joseph Mendoza.

visit_type: Annual

met_with: Joseph Mendoza


facility_name: RPYHPC

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) David Hiett conducted a pre-licensing inspection for a Group Home (Youth Homelessness Prevention Center) license and met with the Chief Operating Officer Debi Himovitz. The entire home was toured, inside and out. The application is to provide 24-hour awake care, trauma-informed environment for 7 homeless youth or youth at risk of homelessness. The building is a duplex with attached left and right units.. The left unit consists of a reception area, 2 offices, a kitchen, and a dining area. A washer and dryer set are located in a locked room where chemicals are stored. Knives and toxics are stored in a locked closet in the reception area. The right unit is for clients and has 3 bedrooms with a capacity of 2, 2 and 3 respectively and a bathroom. All bedrooms have adequate dresser and closet space. There are carbon monoxide/smoke detectors throughout the facility along with adequate fire extinguishers. There are 3 complete first-aid kits on property. All required postings are present. There is an exterior building that is used as a therapy room and additional exterior building used for storage. Applicant understands that the hot water temperature must be maintained within the regulation range of 105-120 degrees and was measured at 113F. A copy of this report has been shared with the facility.

visit_type: Prelicensing

met_with: Debi Himovitz


summary: Facility Evaluation

raw_content:
Narrative:
On 11/08/22 at 11: AM, Licensing Program Analyst (LPA) Alyssa Ng made a visit to the facility for a post-licensing inspection. LPA met with Administrator Helen Ayala and was informed of the purpose of the visit. Safety precautions were taken, including pre-visit screening, mask-wearing, and hand hygiene. At 1: PM, LPA Ng and Facility Manager Cynthia Balleza toured the facility inside and out. The facility is single storied and has two double occupancy bedroom and one triple occupancy bedroom. The third bedroom contains a bunk bed and a twin sized bed. All client bedrooms were equipped with comfortable furnishings which included ample storage space for clients' belongings and twin sized beds. Each bedroom has a closet for extra storage space. Client bathroom was clean and furnished with hygiene supplies for each client. The water temperature measured 116.6 degrees F. The thermostat measured 72 degrees. The facility is clean, safe and sanitary. The kitchen was observed to be clean and free of hazards or chemicals. Sharps were located in the staff office. The weekly menu was posted in the kitchen. LPA observed at least 2 days of perishable foods and 7 days of nonperishable foods. The smoke detectors are in working order. No bodies of water on the premises. All walkways were free from debris or hazards. Former clients and staff files were inspected and observed to be complete. Facility has license, grievance procedures, LIC 610C, personal rights posted. There are no citations. An exit interview was conducted, and a copy of this report was provided to Cynthia Balleza, Facility Manager, whose signature on this form confirms receipt.

met_with: Helen Ayala


summary: Facility Evaluation

raw_content:
Narrative:
On 5/12/23 at 10: AM, LPA Ng made an unannounced case management inspection at listed facility for the purpose of an increase in capacity. LPA Ng met with Administrator Helen Ayala. Safety measures were taken such as mask wearing and hand hygiene. In March of 2023, Ruby's Place inquired about a change in capacity due to extra space at the facility. The facility has three buildings. Facility requested a temporary change in capacity from 7 to 14 until their STRTP application is approved and ready for clients. LPA Ng sent out the fire clearance. LPA Ng was notified that the fire clearance was granted. At 10: AM, LPA Ng observed building 1 to have three rooms and all rooms are double occupancy with one triple occupancy room. There was also a room for clients to relax and play. LPA noticed that the rooms had limited storage. Administrator stated that they will have added drawers and lockers for storage. There were also two bathrooms for clients. Administrator also stated that the clients will go to building three for their meals and laundry. At 11: AM, LPA observed building 2 to have two rooms and 1 bathroom. Administrator said that building 2 will only be utilized if there needs to be a ADA room or isolation room due to COVID. LPA Ng will make the changes and update the system to reflect a capacity of 14. At this time, no deficiencies were cited, and a copy of this report was left with Helen Ayala, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On 5/12/23 at 11:15, Licensing Program Analyst (LPA) Alyssa Ng made a visit to the facility for a required annual inspection. LPA met with Administrator Helen Ayala and was informed of the purpose of the visit. Safety precautions were taken, including pre-visit screening, mask-wearing, and hand hygiene. There is a total of three houses. House three is currently licensed with a capacity of 7 beds. House 1 is currently not in use and just passed fire clearance for 7 beds. Facility will use House 1 as a Youth Homeless Prevention Shelter until the facility is licensed for a STRTP. At 11: AM, LPA Ng and Administrator Ayala toured House 3 inside and out. The facility is single storied and has two double occupancy bedroom and one triple occupancy bedroom. The third bedroom contains a bunk bed and a twin sized bed. All client bedrooms were equipped with comfortable furnishings which included ample storage space for clients' belongings and twin sized beds. Each bedroom has a closet for extra storage space. Client bathroom was clean and furnished with hygiene supplies for each client. The water temperature measured 116.6 degrees F. The thermostat measured 72 degrees. The facility is clean, safe, and sanitary. The kitchen was observed to be clean and free of hazards or chemicals. Sharps were in the staff office. The weekly menu was posted in the kitchen. LPA observed at least 2 days of perishable foods and 7 days of nonperishable foods. The smoke detectors are in working order. In March of 2023, Ruby's Place inquired about a change in capacity due to extra space at the facility. The facility has three buildings. Facility requested a temporary change in capacity from 7 to 14 until their STRTP application is approved and ready for clients. House 1 has three rooms and all rooms are double occupancy with one triple occupancy room. There was also a room for clients to relax and play. LPA noticed that the rooms had limited storage. Administrator stated that they will have added drawers and lockers for storage. There were also two bathrooms for clients. Administrator also stated that the clients will go to building three for their meals and laundry. LPA observed House 2 to have two rooms and 1 bathroom. Administrator said that building 2 will only be utilized if there needs to be a ADA room or isolation room due to COVID. No bodies of water on the premises. All walkways were free from debris or hazards. Former clients and staff files were inspected and observed to be complete. Facility has license, grievance procedures, LIC 610C, personal rights posted. LPA Ng interviewed 3 staff. One client was sleep and the other client is off site. At this time, no deficiencies were given, an exit interview was conducted, and a copy of this report was left with Administrator Helen Ayala.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Monica Pavia conducted an unannounced site inspection, on above date. LPA met with and toured the campus with Juanita Pena. The purpose of this inspection was for LPA Pavia to get visualization of where the structures were located on the campus and what each structure was being used for. There are currently no placement's at this time. Records show the last placement at this facility was discharged 1/19/24. There were no Title 22 deficiencies observed or cited on this date.

met_with: Juanita Pena


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Manager (LPM) Carolyn Flynn scheduled a Technical Assistance (TA) meeting, via Teams, on above date and time. Attendees to the meeting were: Nelson Martinez, Carolyn Flynn, Monica Pavia, Jasmine Cardeno, Helen Ayala and Sophora Acheson. The purpose of the meeting was to clarify the youth the facility has been accepting into placement. Ruby's Place is currently licensed as a Youth Homelessness Prevention Center. The facility starting accepting a different population of youth starting October 2023. The facility has a current census of 2, as of today, February 15, 2024. The facility has been working outside of their existing Plan of Operation. The facility is working on an exit strategy of the 2 youth currently placed, as well as submitting a new application for the correct facility type. Deficiency cited 80022(k), Plan of Operation.


facility_name: SANCTUARY, THE

summary: Facility Evaluation

raw_content:
Narrative:
Complaint Specialist C.K. Kinney(CS) traveled to The Sanctuary to conduct a Case Management inspection due to facility closure. CS met with Chrystal Sheets(S1), toured the facility. CS observed the facility is not in operation. CS and S1 dicussed future plans for the building. S1 surrendered the facility License to CS at conclusion of the facility tour. No deficiencies observed or cited during this inspection. Copy of this report provided to S1 at conclusion of inspection.

met_with: Chrystal Sheets


facility_name: SAY - RIPLEY SHELTER

summary: Facility Evaluation

raw_content:
Narrative:
On 5/21/ Licensing Program Analyst (LPA) Cheyenne McCambridge conducted an unannounced inspection visit to the above facility for the purpose of conducting an Annual/Required inspection. LPA McCambridge met with shelter staff Jasmine Rizo and toured the facility, inside and out. This facility is licensed as a runaway youth shelter with a capacity of six clients, there are currently no clients in care. Upon inspection, the facility is clean, safe, sanitary, and in good repair. All passageways are unobstructed. There are no bodies of water. No room commonly used for other purposes is used as a bedroom. All bedrooms (four) have adequate closet and drawer space and are furnished accordingly. The home is maintained at a comfortable temperature and the water temperature measured 113 within the regulation. Although there are no clients in care the facility had required perishable and non-perishable food supply. Sharps are kept locked in an office cabinet and toxins are kept locked in laundry room and hall closet. There are carbon monoxide and smoke detectors throughout the facility that work and are active. There are complete first-aid kits located in the facility. There are no firearms on the property. The facility has client personal rights and menu posted in clear view. Staff files were reviewed. All files appeared complete. No clients in care, however LPA McCambridge reviewed client intake documents and medication forms all required documents were included. No deficiencies were cited. An exit interview was conducted and a copy of the report was emailed to the facility.

met_with: Jasmine Rizo


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Cheyenne McCambridge and Brian Bertoli made an unannounced case management inspection, and met with Chief Program Officer (CPO) Elizabeth Goldman and shelter staff member Jasmine Rizo. The purpose of the inspection was to review current issues at the facility. LPAs and Goldman discussed administration issues and the process of changing the administrator to Elizabeth Goldman. Documents will be submitted to make the change this week. LPAs toured the facility. The facility is clean, safe, sanitary, and in good repair. No youth were present. LPAs reviewed facility's monthly report on youth activity and participation for September and facility will send report for September 2021 for comparison. LPAs discussed termination of prior Administrator and the potential impact on the facility. CPO Goldman stated that there has been no impact financially. Supplies have been adequate and there has been no impact on the youth or the services provided. No deficiencies observed or cited during this inspection. An exit interview was conducted with CPO Goldman and a copy of this report was sent to the facility.

met_with: Elizabeth Goldman


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst Brian Bertoli made an unannounced visit to the facility. The purpose of the visit was to determine the operational status of the facility. Recent news reports indicated the SAY organization was having financial difficulties and had laid off most of their employees. LPA Bertoli knocked on both front doors and rang the doorbell and their was no response. The doors were locked and there was no sign of activity on the premises. There appeared to be a lack of maintenance by leaves covering the walkways. There was a sign on the ground indicating "Staff and drop in services are currently unavailable' with a number to call for a crisis line - 888 729-0012. LPA Bertoli called the number and left a voicemail message asking for status of the facility.

met_with: No staff present


facility_name: WAYMAKERS TUSTIN YOUTH SHELTER 2

summary: Facility Evaluation

raw_content:
Narrative:
On July 3,2025 at 9: AM, Licensing Program Analysts (LPAs) Guadalupe Munoz conducted an announced pre-licensing inspection of the facility.. LPA met with Facility Administrator Melissa Whitworth and Program Director, Lisa Samaan. The facility is a three bedroom two bathroom two story home with an attached garage. The applicant is applying for a Group Home Youth Center Homelessness Prevention Center with the capacity of six ambulatory clients aged between 12-17 years old. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. Clients will have access to use multiple cordless telephones to make and receive confidential telephone calls. The facility smoke detectors and carbon monoxide detectors tested and were observed to be in working order; the fire extinguishers are properly charged and serviced. The facility has a first aid kit that has all of the required items. The applicants stated there were no weapons in the facility. Disinfectants and cleaning solutions will be stored and locked in storage closet. Sharp knives will be stored in a locked cabinet in the kitchen. Medication will be locked and stored in a cabinet in the staff office The following required forms need to be posted in the facility: Personal Rights, LIC Emergency Disaster Plan, and Grievance Policy, and Removal and/or planned discharge policy. The facility is set up as follows The entry hallway leads in two directions, to the right an open living room that flows into the study hall and to the left a hallway leads to the dining room and attached kitchen. The open study hall area for clients has desks and chairs with a printer to complete school work and meet with a tutor. The dinning room is located next to the kitchen and contains dining room table where meals will had in family style. The kitchen is attached to dining area and contains dishwasher, fridge and other small appliances. At the rear of the home past the dining room is a staff office that will contain staff and client files, centrally stored medication and other facility logs. All shared living spaces have furniture in good condition. This area also contained books, television and other recreational items. There are three client bedrooms that are designated for two clients per room with twin sized beds dresser and closet space for each client. Bedroom #1 is located downstairs: it designated for two clients, with two twin beds, two dressers and closet spaces. Bathroom #1 is located downstairs: It is located inside of bedroom #1 for client use. Bedroom #2 is located upstairs: it is designated for two clients, two twin beds, it has two dressers and closet space. Bathroom #2 is located upstairs: It is shared by clients in bedrooms #2 and # Bedroom #3 is located upstairs: it is designated for two clients, two twin beds, two dressers and closet space. Bathroom #3 is located downstairs next to laundry area: it is designated for guest use. Each room has adequate clean linens, pillows, blankets, comforters, mattress pads, and mattresses pads. Each bedroom had adequate lighting. LPAs observed the following areas that need to be corrected: Posting the required forms and information Seven days supplies of nonperishable food 2 days supplies of perishable food 3 day of emergency supply food Based on the facility pre-licensing inspection, the facility will make the corrections and provide LPA Munoz will verification of items purchased and posted to complete pre licensing inspection. All special incident reports (SIR's) will be sent via e-mail to: cclpaccr@dss.ca.gov. The reporting requirements were reviewed with the Applicant on this date. LPA explained that once the license is approved, all employees shall have an approved criminal record clearance for CCL and be associated to this facility. LPAs conducted exit interview with Facility Administrator, Melissa Whitworth and Program Director, Lisa Samaan and provided them with a copy of this report.

met_with: Lisa Samaan and Melissa Whitworth


summary: Facility Evaluation

raw_content:
Narrative:
On 10/01/25 at 10: AM, Licensing Program Analyst (LPA) Guadalupe Munoz met with Melissa Whitworth, Program Supervisor/Administrator for the purpose of conducting a post licensing inspection of the facility. Currently there are two residents in the home. The facility is Group Home Youth Homelessness Prevention Center with the capacity of six ambulatory clients aged between 12-17 years old. The facility is a two story home with three bedrooms, two bathroom and with an attached garage. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. Clients have access to use of multiple cordless telephones to make and receive confidential telephone calls. The entry hallway leads in two directions, to the right an open living room that flows into the study hall and to the left a hallway leads to the dining room and attached kitchen. The open study hall area for clients has desks and chairs with a printer to complete school work and meet with a tutor. The dinning room is located next to the kitchen and contains dining room table where meals will had in family style. The kitchen is attached to dining area and contains dishwasher, fridge and other small appliances. At the rear of the home past the dining room is a staff office that will contain staff and client files, centrally stored medication and other facility logs. All shared living spaces have furniture in good condition. ****** There are three client bedrooms that are designated for two clients per room with twin sized beds dresser and closet space for each client. Bedroom #1 is located downstairs: it designated for two clients, with two twin beds, two dressers and closet spaces. Bathroom #1 is located downstairs: It is located inside of bedroom #1 for client use. Bedroom #2 is located upstairs: it is designated for two clients, two twin beds, it has two dressers and closet space. Bathroom #2 is located upstairs: It is shared by clients in bedrooms #2 and # Bedroom #3 is located upstairs: it is designated for two clients, two twin beds, two dressers and closet space. Bathroom #3 is located downstairs next to laundry area: it is designated for guest use andstaff use.. Each room has adequate clean linens, pillows, blankets, comforters, mattress pads, and mattresses pads. Each bedroom had adequate lighting. The facility smoke detectors and carbon monoxide detectors were tested and were observed to be in working order. The fire extinguishers are properly charged and serviced. The facility has a first aid kit that has all of the required items. Program Director stated there were no weapons in the facility. Disinfectants and cleaning solutions are stored and locked in storage closet. Sharp knives are stored in a locked cabinet in the kitchen. Medications are locked and stored in a cabinet in the staff office The following required forms were posted in the facility: Personal Rights, LIC Emergency Disaster Plan, Grievance Policy, and Removal and/or planned discharge policy. LPA reviewed two client files and five staff files. LPA conducted staff and client interviews. LPA conducted exit interview with Facility Administrator, Melissa Whitworth and Program Director, Lisa Samaan and provided them with a copy of this report and LIC 811.

met_with: Melissa Whitworth, Program Supervisisor


facility_name: CSP HUNTINGTON BEACH YOUTH CENTER

summary: Facility Evaluation

raw_content:
Narrative:
On July 13, 2022, Licensing Program Analyst (LPA) Eduardo Barragan travelled to CSP Huntington to conduct an annual inspection with Maria Isabel Kluwe, Program Director Of Client Care and Gail Munoz Salina, House Supervisor. An inspection of the facility was conducted, and the following was observed: There are currently six clients in placement. LPA toured the facility indoors and outdoors. The fire extinguisher was charged and up to date. Hot water temperatures last measured up to 104 degrees in the home. LPA observed adequate supply of non-perishables. LPA observed adequate supply of furnishings, linen and storage space for clients. Cleaning chemicals were inaccessible to clients. Medication area was centrally stored and locked. There are no pets at the facility. Per the Administrator and House Supervisor, there are no weapons at the facility. There were no pools at the facility. LPA Barragan will be returning to complete the annual inspection at a later date and time.

met_with: Maria Isabel Kluwe and Gail Munoz Salinas


summary: Facility Evaluation

raw_content:
Narrative:
On August 04, 2022, at 9:35 am, Licensing Program Analyst (LPA) Eduardo Barragan arrived to CSP Huntington Beach Youth Center to continue the annual inspection that began on July 13, 2022. LPA Barragan with Maria Isabel Kluwe, Program Director, Gail Munoz Salinas, House Supervisor, and Nancy Galeana, Program Director. LPA Barragan reviewed three staff files on this date. LPA Barragan reviewed five client's files on this date. LPA Barragan Interviewed 3 staff on this date. LPA Barragan Interviewed 2 client and three client refused to be interviewed on this date. One deficiency was cited and four technical violations were administered on this date. LPA Barragan conducted an exit interview. A copy of this report and appeal rights were provided to Maria Isabel Kluwe, Program Director, Gail Munoz Salinas, House Supervisor, and Nancy Galeana, Program Director..

met_with: Maria Isabel Kluwe, Gail Munoz Salinas, and Nancy Galeana


summary: Facility Evaluation

raw_content:
Narrative:
On March 13, 2025, at 09: AM Licensing Program Analyst (LPA) Gilbert Marquez met with Administrator/Program Director, Nancy Galeana, for the purpose of conducting an annual inspection of the facility. LPA Marquez and Administrator Nancy Galeana toured the physical plant, outside and inside. Review of the facility's operations shows that the facility is licensed to serve twelve clients ages 11 - 17 years of age. The facility currently has three clients in care at this time, and there were three clients present during the inspection. LPA Marquez noted that the facility has an interior and exterior camera system that monitors the common areas of the facility. Facility has six bedrooms, with separation of three bedrooms on the east side of facility to occupy six female clients and three bedrooms on the south side of facility to occupy six male clients. There is adequate shelf and closet space for client's belongings. There is a fireplace located in the living room which is properly screened. There is a staff office located next to the dining room and game room. The client and staff records are located and locked in the staff office in file cabinets. There is also a school room, social worker's office, and director's office. The medication and first-aid kit are stored in the locked medication cabinet in the staff office. There was only one client taking prescribed medication at the time of this inspection. The medication log was kept updated. The cleaning products and sharps are stored in the locked closet near dining area. The facility is clean, organized and in good repair. The facility has a sufficient supply of sheets, bedding and linens. **Continued on LIC809-C** **Continued from LIC809** Emergency exits were free from obstruction. The facility's smoke detectors in bedrooms and hallways were checked and were operable. All smoke detectors are connected to a fire safety monitoring agency contracted by the city due to the building being owned by the city of Huntington Beach. A copy of the alarm system maintenance check that was conducted on 02/10/2025 was given to LPA. There are no guns or weapons in the facility as stated by Administrator Galeana. The following required posted items were observed accessible to clients: Grievance Procedures, Personal Rights, Ombudsman Poster, Visitation policies, and current menu. Hot water temperature was tested at 116.3 degrees Fahrenheit in the boys bathroom, which is within regulatory requirements of 105 degrees to 120 degrees. LPA observed a minimum seven day non-perishable, and a two day perishable supply of food. There was a variety of snacks available for clients as well. Three staff (S1 - S3) out of thirty-two staff were interviewed, and two of three clients (C1 and C2) were interviewed as part of the inspection. A sample of client and staff files were reviewed during the inspection. LPA reviewed two out of five volunteer files (S6-S7). LPA reviewed five out of thirty-two staff files (S1-S5), please refer to Confidential Names List (LIC811). All the files reviewed were organized and contained all pertinent documents required per Title 22 regulations. All staff that work at the facility have Department of Justice, Federal Bureau of Investigation, and Child Abuse Clearance Index clearances. Based on the facility inspection file reviews, and interviews of staff and clients, there are no deficiencies found at this time. A copy of this report was reviewed and given Administrator Nancy Galeana along with a Confidential Names List (LIC 811).

met_with: Nancy Galeana, Administrator


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews revealed that the sexual interaction between C1 and C2 was consensual. Confidential interviews also revealed that staff checked on C1 and C2 10-20 times throughout the course of the evenings due to C1 and C2 not immediately falling asleep at 9pm. Confidential interviews resulted in conflicting statements as to whether or not the sexual interaction between C1 and C2 was consensual or not. Based on confidential interviews, and records reviewed, the allegation that C1 was sexually assaulted by C2 while in care is unsubstantiated. Meaning, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of this report, along with the appeal rights were explained to Administrator Nicole Hernandez. Due to printer malfunction, this report will be emailed to Administrator Nicole Hernandez.

Investigation Findings:
13On October 27, 2022 at 10:20am, Licensing Program Analyst (LPA) Adrian Mendez conducted an unannounced inspection with the facility and met with Administrator Nicole Hernandez of CSP Children's Residential Program Tustin to discuss the investigative findings for the allegation noted above. The investigation was conducted by Community Care Licensing Investigations Branch (IB) Special Investigator Annette Renquist and included interviews with two children (C1, C2), five facility staff (S1, S2, S3, S4, S5), two biological parents (BP1, BP2), and one Tustin Police Department (PD) Detective (A1). In addition, county records, facility records, and medical records were reviewed. Investigator Renquist also reviewed Tustin PD report CR# 22-5894. On August 1, 2022, the Department received an allegation that a minor was sexually assaulted by another minor while in care. It was reported that C2 sexually assaulted C1 on three different nights at the facility. It was also reported that the incidents occurred after 9pm. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Adrian Mendez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: CSP CHILDREN'S RESIDENTIAL PROGRAM TUSTINFACILITY NUMBER: VISIT DATE: 10/27/2022

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

report_type: Complaint Investigation

met_with: Nicole Hernandez

complaint_status: unsubstantiated


raw_content:
Narrative:
that C1 was sexually offended by an unknown client, no specific date was given. Confidential interviews revealed that the facility was in compliance with staffing ratios per regulations for the given month that the alleged incident occurred. Confidential interviews and documents reviewed indicated that C1 has a history of making statements for attention. Due to C1 not being able to be interviewed and no witnesses to the alleged incident, there is not a preponderance of evidence to support the allegation. Based on confidential interviews, that due to lack of supervision minors engaged in inappropriate interactions with each other, may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. Facility Administrator, Nicole Hernandes was on the speaker and authorized Bryn Early to sign LIC 809. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with facility representative Byn Early . Due to printer malfunction a copy of this report, LIC 811, and appeal rights was will be emailed to the Administrator.

Investigation Findings:
13On June 14, 2024, at 1: PM, Licensing Program Analyst (LPA) Guadalupe Munoz arrived unannounced at the facility and met with Bryn Early, voluteer Coordinatorto, discuss the investigative finding for the allegation noted above. LPA conducted an inspection of the facility on 9/28/23 at 1:15 pm and no deficiencies were observed. LPA Interviewed three staff (S1-3) and attempted to interviewed two clients (C1, C2), however after several attempts LPA was unsuccessful to make contact, LPA interviewed C1's bio-mom. LPA obtained and reviewed the following documents: C1's daily shift notes, Staff Schedule, Client Roster, Investigation Branch Report and Incident Reports. On 09/21/2023, Community Care Licensing (CCL) received an allegation that due to lack of supervision minors engaged in inappropriate interactions with each other. During the investigation, there was no corroborating evidence to support the above allegation. Although the Department received information UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Guadalupe Munoz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ORANGE COUNTY RO, THE CITY DR., SUITE FACILITY NAME: CSP CHILDREN'S RESIDENTIAL PROGRAM TUSTINFACILITY NUMBER: VISIT DATE: 06/14/2024

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

met_with: Bryn Early and Nicole Hernadez on phone


facility_name: CSP CHILDREN'S RESIDENTIAL PROGRAM TUSTIN

summary: Facility Evaluation

raw_content:
Narrative:
On August 24, 2022, at, 10:45 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility for the purpose of a required two year inspection of the facility . LPA Linley met with Nicole Hernandez, Facility Administrator and Carol Carlson Program Director. The facility was toured inside and out. The facility is a group home (Youth Homelessness Prevention) that shelters children for up to 21 days. The facility has a capacity of 6 ambulatory male and female clients, ages 11-17 years. Current census of three clients. The facility is set up as follows: There are three upstairs bedrooms which each has two twin beds with adequate dresser, desk and closet space. There are two upstairs bathrooms that are used by all the clients. There is a downstairs restroom that is used for staff and an outside guest restroom that is located next to the Therapist office. The cleaning products are stored and locked in the laundry room by the staff office. There is a staff office located next to the living room and study area. The client records are located and locked in the staff office in file cabinets. The staff files are located and locked in a file cabinet in the Administrator's Office. The medication and first-aid kit are stored in the locked medication closet in the staff office. Additional storage and file cabinets are stored in the garage which is a non-programming area. The Administrator's office is located upstairs with an attached balcony and a Therapist office which is detached from the main home. Bedrooms are arranged so that no more than two children shares a room. No room commonly used for other purposes was used as a bedroom, and no bedroom serves as a passageway to another room. There was adequate drawer and closet space for children's belongings. There is sufficient linens, blankets, towels and pillows. The smoke detectors and carbon monoxide detectors were checked and were working properly. The garage is maintained locked and consists of an extra refrigerator, washer/dryer, cleansers/chemicals locked in cabinet and extra PPE locked in a cabinet. Sharp knives were inaccessible and stored and the locked in the staff office. First Aid kit was accessible and had all required items. *** There were no guns or weapons as stated by administrator. The hot water temperature was tested and noted to be at 105 degrees and maintained within the regulation range of 105-120 degrees. The facility has a fully sufficient food supply, including a sufficient supply of fresh fruits, vegetables, can goods, meats and staples. No expired food was located in the supply. The facility has a sufficient supply of sheets, bedding and linens. There is a fireplace located in the living room and the Therapist office and it is properly screened. There are five fire extinguishers throughout the facility. There is an outside secured gated pool located in the backyard that is used for water therapy and recreational use. Staff are in the process of taking Water Safety Certification courses through the Red Cross. The facility staff use their own vehicles to transport clients and the facility leased van. LPA completed the inspection of ten of twenty staff files (S1-S10) (see confidential name list, LIC811, dated 08/24/2022) three of three staff were interviewed (S5, S11, S12). LPA completed the inspection of three of three client files and three clients (C1-C3) were interviewed. During the inspection and file review, no further deficiencies were observed. Exit interview conducted, copy of LIC 809 report was provided. Due to printer malfunction, a copy of the report will be emailed to the Administrator. A copy of the report will be placed in the facility file.


summary: Facility Evaluation

raw_content:
Narrative:
On 03/27/25 at 9:35 am, Licensing Program Analyst (LPA) Gilbert Marquez arrived unannounced at the facility for the purpose of an annual inspection. LPA met with Nicole Hernandez, Administrator and House Supervisor. The facility was toured inside and out. The facility is a group home (Youth Homelessness Prevention) that shelters children for up to 21 days. The facility has a capacity to serve six ambulatory male and female clients, ages 11-17 years. Current census is one client. The facility is set up as follows: Upstairs there is the Director's office, and three upstairs bedrooms which each has two twin beds with adequate dresser, desk and closet space. There are two upstairs bathrooms that are used by all the clients and are gender specific. There is a separation between bedrooms #1 and #2, and bedroom #3 so that females and males are not intentionally co-mingling. Bedrooms are arranged so that no more than two children share a room. No room commonly used for other purposes was used as a bedroom, and no bedroom serves as a passageway to another room. The staff files are located and locked in a file cabinet in the Director's office. There is a downstairs staff only restroom. Continuing downstairs, there is a staff office located next to the living room and study area. The client records, medication and client monies (if any) are located and locked in the staff office. A first aid backpack with all the required supplies is located in the staff office. Additional storage and file cabinets are in the garage which is detached from the main building, and a non-programming area. The cleaning products are stored and locked in the laundry room by the staff office. There is sufficient linens, blankets, towels and pillows. Sharp knives were inaccessible and stored and the locked in the staff office. First Aid kit was accessible and had all required items. There were no guns or weapons as stated by administrator. **CONTINUED ON LIC809C**z **CONTINUED FROM LIC809** The hot water temperature was tested and noted to be at 109.8 degrees Farenheit and maintained within the regulation range of 105-120 degrees. The smoke detectors and carbon monoxide detectors were checked and were working properly. There are five fire extinguishers throughout the facility and were properly maintained. The facility has a fully sufficient food supply: seven days of non-perishable food, and two days of perishable food. No expired food was located in the kitchen or pantry. There is a fireplace located in the living room and the Therapist office and it is properly screened. There is an outside secured gated in-ground swimming pool located in the backyard that is used for water therapy and recreational use. The gate of the fence swings away from the pool, self-closes and has a self-latching device located no more than six inches from the top of the gate.The fence is constructed so that the fence does not obscure the pool from view. Staff are Water Safety Certified through the Red Cross. The staff use a facility van for transport to activities outside of the facility. Guardians take children to all doctor appointments, and school visits during their staff at CSP. Facility van is maintained by the dealership, and there were no maintenance lights displayed on the vehicle dashboard. LPA completed the inspection of five staff files (S1-S5), see confidential name list LIC811. Two of thirty one staff were interviewed (S1 and S2). LPA completed the inspection of one of one client files and one client (C1) was interviewed. Based on the facility inspection, files reviewed, and interviews, there are no deficiencies found at this time. An exit interview was conducted, and this report was explained. A copy of this report and Confidential Names List LIC 811 were given to Administrator/House Supervisor Nicole Hernandez


facility_name: WIND YOUTH SERVICES-NAVINA'S HOME

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPAs) Stephanie Lor and Tana Kinder conducted an unannounced inspection on 12/2/21 for the purpose of interviewing the youth that resides in the facility related to the 2 year inspection on 12/1/21. No citations were given. An exit interview was conducted and a copy of this report was provided to the manager.

met_with: Alyssa Sharrock, Shelter Staff


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst, (LPA) Tana Kinder conducted an inspection to review the personnel files, with the Shelter Program Manager. This was related to the 2-year inspection conducted 12/01/2022. No citations were issued. A copy of this report was provided.

met_with: Shelter Program Mgr.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced 2-year required inspection was conducted by Licensing Program Analyst (LPA) Tana Kinder 12/01/2022 at 215pm. LPA Kinder confirmed prior to the inspection that no staff or clients were experiencing health symptoms related to Covid-19. Criminal record clearances were reviewed, and the facility is in compliance. There are 32 people associated to the license. The licensing fees are current. Community Care Licensing file, unusual incident reports, facility roster, facility profile and complaint history were reviewed prior to inspecting the facility. The licensing fees are current. The Youth Homelessness Prevention Center is licensed for 6 youth and has no youth currently placed at this time. There are 10 staff members currently working at the facility. LPAs reviewed 5 staff files. Files reviewed were complete and up to date with current required documentation. The facility was inspected jointly with LPA and the program manager. A copy of the license, personal rights and emergency exit plan are prominently posted. Client and staff files are in locked cabinets, located in the office. Smoke detectors are in working order, there is a carbon monoxide monitor located in the hallway. A fully charged fire extinguisher is located in the kitchen. There are 3 bedrooms with 2 beds in each bedroom. Each client is provided with a bed, dresser space, closet space and a night stand. There are 2 bathrooms. There is a hall closet with additional linen if needed for the bedroom and the bathroom. The kitchen was accessible by the clients. LPA tested the water temperature at multiple faucet locations and the hot water reading was between 105-120 at all locations. Continued... LPA inspected the grounds of facility. There is a back patio area, accessible by the youth. The walkway from the front to the back of the facility was clear. There was a shed in the backyard that had past youth's property that was left behind and seasonal decorations stored. The facility vehicle has current insurance and registration. No Title 22 deficiencies were cited today during the inspection. An exit interview was conducted and discussed with Lornetta Brown, program manager, and a copy of the 2-year inspection report was provided and the appeals process.

met_with: Program Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 12/4/2024 at 10: AM Licensing Program Analysts (LPAs) Sarina Buchannan and Tatyana Shulz made an unannounced visit with the purpose of conducting an annual inspection to the above facility using the Compliance and Regulatory Enforcement (CARE) tool. LPAs met with Elisa Sharrock, Shelter Support Staff and a walk through of the interior and exterior was completed. The facility serves up to 6 ambulatory female and male homeless or runaway clients between the ages of 12-18 years old, placed privately. Clients average length of stay is up to 18 months. Physical Plant Room 1 is a visit and activities room that has 1 couch, 2 chairs, a television, and a Playstation. Room 1 also has a closet that is used for storing donation items. Room 2 is a dining room that has a table with ample seating, a couch, and board games such as Connect 4 and Jenga. Room 3 is a staff office with a monitor that shows a live stream of facility cameras in the home, all cleaning supplies are locked in the closet, sharps are stored in filing cabinet, client medications stored in the filing cabinet, and client files. Room 4 is the kitchen with a working stove, a food pantry, a combination refrigerator and freezer, and a staff only stand up freezer. Room 5 is the laundry room with a washer, dryer, mops, the facilities water heater, and a lock ensures that the room is inaccessible to clients. Room 6 is the client bedroom with 2 dressers, 2 twin XL beds, and 2 caddies for toiletries. Room 7 is a bathroom with a working toilet and a trash can with a lid. Room 8 is a bathroom with a working toilet, a trash can with a lid, and a paper towel dispenser. Room 9 is a client bedroom with 2 dressers, 2 twin XL beds, and an exit to the backyard. Room 10 is a client bedroom with 2 dressers, 2 twin XL beds, and a closet with a door. In the hallway is a linen closet with extra sheets and blankets. The 2 client bathrooms are located in the hallway and have water temperatures of above 125 degrees Fahrenheit. There were signs posted that informed clients of the water temperature in each bathroom. The backyard is gated, with 2 hammocks, 2 tables, and a shed. The backyard is clear of debris and clean. There are 9 total cameras at the facility grounds in the following locations: 2 pointed at the driveway, 2 pointed at the front porch, 2 in the backyard, 1 in the staff office, 1 in the activity room, 1 in the dining room. (continued on LIC 809C)(Page 1) The following required documents were posted, License and Personal Rights. Disinfectants/cleaning solutions inaccessible to children in care. Refrigerator Temperature at or below 45 degrees Fahrenheit. Nonperishable foods one week and fresh perishable foods two days minimum. Menu present and posted in the kitchen area on the fridge. A working telephone is available at the facility. Carbon monoxide and smoke detectors are in working order. First Aid Kit is fully stocked. No Medication at the facility due to no clients being in care, medication logs were kept and stored in the office. A Fire Extinguisher is up to date and in working order. Toilets, wash basin, and bathtub are in good repair. Soap and Paper towels are available to clients. The facility is free of vermin. The following domains were also reviewed during today's inspection Physical Plant, Operations, Disaster Preparedness, and Emergency Interventions. CARE tool found the client and staffing file domains to be not applicable but LPAs Buchannan and Shulz conducted client file reviews of clients no longer in care. LPAs reviewed a total of 5 client files. LPAs were unable to conduct staff file reviews due to Administrators not being present and facility staff not having access to them. LPA also conducted 1 staff interview and no concerns for follow up were noticed. A review of the Licensing Information System indicates the facility is up to date on their facility fees and all the staff were fingerprint cleared and associated to the facility. Upon inspection and file review the following deficiencies were observed: A large crack in the Window in a client bedroom (Room 10) - LPAs observed glass company to arrive at 4: PM on 12/4/24 and provided a repair estimate of 7 days. A missing air conditioning vent cover in a client bedroom. (Room 6) A hole in the door in the client bedroom. (Room 6) An electrical outlet behind the headboard of bed is missing a cover exposing the inside of the socket in the clients bedroom. (Room 9) Both window screens are bent and/or ripped in the staff office with items that need to be inaccessible to clients. Windows screen being bent allows access into staff office from the front and backyard. (Room 3) A missing shower head making the shower inoperable in 1 client bathroom. (Room 7) There is buildup of debris on the air vent in the hallway that needs to be cleaned and/or replaced. There are 3 planks on the outdoor fence which are falling off exposing the roadway. (Continued on LIC 809C) (Page 2) The facility is not having youth sign and date their personal property/resource logs upon discharge making it not possible to verify if clients are receiving their belongings upon exiting. LPAs were unable to review monthly client roster reports and board minutes due to there being no authorized employee to give LPAs access. There were no records of staff emergency disaster drills being conducted since 6/8/2021. The facility is being cited during todays inspection see (LIC 809D) and (LIC 9102TV). A follow up inspection will be conducted at a later date to conduct staff and client file reviews. An exit interview was conducted with Elisa Sharrock and a copy of this report was emailed on 12/5/24. Appeal Rights were provided during inspection. (Page 3)

met_with: Elisa Sharrock, Shelter Support Staff


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
On December 12, 2024 at 11: AM Licensing Program Analysts (LPAs) Sarina Buchannan and Tatyana Shulz made an unannounced visit with the purpose of continuing the annual inspection to the above facility using the Compliance and Regulatory Enforcement (CARE) tool. LPAs met with Lornetta Brown, Facility Administrator and a walk through of the interior and exterior was completed. The facility serves up to 6 ambulatory female and male homeless or runaway clients between the ages of 12-18 years old, placed privately. Although the program statement states the length of stay is up to 18 months, facility confirmed clients stay a maximum of 21 days. As of today, the census is 2. On December 4, LPAs Buchannan and Shulz began the annual inspection using the CARE tool and the following domains were reviewed and completed: Physical Plant, Operations, Disaster Preparedness, and Emergency Interventions. CARE tool found the client and staffing file domains to be not applicable but LPAs Buchannan and Shulz conducted client file reviews of clients no longer in care. LPAs reviewed a total of 5 client files. LPAs were unable to conduct staff file reviews due to Administrators not being present and facility staff not having access to them. During today's inspection LPAs Buchannan and Shulz reviewed the following domains: Client records and staffing. LPAs reviewed 2 client record and 5 staff records. LPA conducted 1 staff interview and 1 client interview during todays inspection. Upon staff record review LPAs noticed the following deficiencies: 2 staff files are missing their tuberculosis screenings All staff files are missing the required initial 24 hour training log 4 staff files had CPR and First Aid that expired in 2023 Staff file was missing their signed job description (Report continued on LIC 809C) LPA's also observed that the vent in the hallway has been cleaned and no longer has a build up of debris. The shower head in the client bathroom was also replaced while LPAs were present. LPAs were provided a monthly written report for the month of November 2024. Exit interview conducted and a copy of this report and appeal rights were emailed to Lornetta Brown, Facility Administrator.

Deficiencies:
80066(a): Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information
84065(i): Personnel Requirements

(i) Notwithstanding Sections 80065(f)(1) through (6), new child care staff hired on or after July 1, 1999, shall complete a minimum of 24 hours of initial training comprised of the 8 and 16-hour training as specified in (1) and (2) below

met_with: Lornetta Brown, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 01/10/2025 at approximately 10: AM Licensing Program Analyst (LPA) Sarina Buchannan and Licensing Program Manager (LPM) Rosa Rodriguez conducted an in-person Informal Meeting with the above facility for the purposes of discussing compliance and regulations. Present during the meeting were LPA Sarina Buchannan, LPM Rosa Rodriguez, Chief Executive Officer Miren Hower, and Facility Administrator/Facility Manager Lornetta Brown. Below is a summary of the topics that were discussed and the answers that were provided by the licensees: Program Statement - LPA and LPM reviewed the LIC 9106 to discuss updates needed. Licensee stated they will update necessary sections of the LIC 9105 and Program Statement to reflect current program and population. Licensee stated they will begin the review and submit the updated Program Statement and LIC 9106 to the department by 4/15/25. LPA and LPM will review the new Program Statement to determine if the new revisions are in compliance with the department regulations. Client Population Served - LPA and LPM informed facility that the fire clearance granted on 11/28/26 states the clearance was granted for 6 ambulatory residents only. Facility will update their program statement to reflect correct client population served. Guardian Roster - Licensee stated that they do not have access to Guardian since being released from their contract with GoodWill and are therefore unable to associate or disassociate staff. Licensee stated they are going to either request new access or, if possible, will create a new Guardian profile if necessary. Licensee also stated they will attend the next Guardian Webinar for providers to gain knowledge on how to use and access Guardian. (report continued on LIC 812C) 4. Reporting Requirements - Licensee stated that they have not submitted any Unusual/Incident Reports for the entire year 2024 due to there being no circumstances that warranted them. LPA reminded Licensee that Medications errors were not being reported and needed to be. Licensee stated they will now be submitting Incident Reports for medications. LPA and LPM also reviewed the Reporting Requirements with Licensees and they understood the reporting timeline and the behaviors and situations that need to be reported to the department. LPA discussed the Incident report submitted to LPA Buchannan on 12/11/24. Licensee stated they will submit their 7 day report by 1/13/25 and will now submit all incidents to the LPA of the day instead of LPA Buchannan. All reports will now be submitted to CCLSacchicoincidents@dss.ca.gov. 5. Physical Plant - Licensee informed LPA and LPM that their previous maintenance person was contracted through GoodWill and the facility had been having difficulty finding a new maintenance person. Licensee stated they have now hired a maintenance person and have also created a binder that will contains all work order requests and completions. 6. Human Resources - Licensee stated that their Human Resources department was being ran by GoodWill. Licensee stated that when their GoodWill contract ended they did not give the facility personnel and client files. Licensee shared that they have had issues with locating files, finances, and all Human Resource documents needed. Facility stated they are in the process of transferring all personnel files to a virtual version but will be working on organizing physical versions of client files. 7. Pending and Cleared Citations - LPA and LPM reviewed the pending and cleared citations with Licensee. Licensee received Hour initial training's for staff dated 12/9/24, 12/26/24,1/2/25, and another training was completed on 1/2/25. Facility also provided staff training's on Client Personal Resource Log. Licensee stated they will use CCLs Personal Resource Log for the future to ensure clients sign in and out their property. Licensee also stated they will provide a signed Copy of their board minutes to LPA by 1/13/25. Additionally, Licensee informed LPA Buchannan via text on 1/7/24 that the window screens will be delivered on 1/15/25 but will still need additional time to be installed. LPA Buchannan and LPM Rodriguez offered up the opportunity for discussion and questions and Licensees did not have any more to add. LPA and LPM informed Licensee they will be referring them for the Technical Support Program (TSP) and Licensee were in agreement to get the referral to TSP. LPA stated they will follow up regarding additional resources and Technical Support Program. LPA and LPM thanked Licensees for their time and concluded the Informal Meeting.

met_with: Miren Hower (Chief Executive Officer), Lornetta Brown (Facility Administrator)


summary: Facility Evaluation

raw_content:
Narrative:
On 07/01/2025 at approximately 10: AM Licensing Program Analyst (LPA) Sarina Buchannan conducted an in-person office meeting to go over updated required revisions of the program statement. Present during the meeting were LPA Sarina Buchannan, Chief Executive Officer Miren Hower, and Program Administrator/Facility Manager Lornetta Brown. Below is a summary of the topics that were discussed and the answers that were provided by the licensees: A Documents - LPA reviewed information that was missing in the LIC 215, LIC 500, LIC 401, LIC 503, LIC 610C, and LIC 999. LPA confirmed that Licensee will update the forms and add the LIC 401A, LIC 403, and LIC 404. Section 3 - LPA reviewed this section with Licensee and they explained how they will monitor educational progress. Licensee will update this section to include this. Section 5 - LPA reviewed this section with the Licensee and they explained their special services/programs and how they will be offered. Licensee will update this section to include this. Section 6 - LPA reviewed this section with the Licensee and they discussed they will remove acronyms and maintain record for 3 years instead of 1 year. Licensee will also specify which staff will help with the medication dispensing and destroying. Section 7 - LPA reviewed this section with Licensee who stated they will clarify who can transport clients as well as what activities they will be transported to. They will also indicate staff cannot use their personal vehicles. (report continued on LIC 809C) Section 8 - LPA reviewed this section with Licensee and discussed the violations of Title 22. Licensee will remove, update, and modify this section in order to meet regulations. Licensee will make this section more clear and concise by explaining intake and intake procedures in further detail. Section 10- LPA reviewed this section with Licensee and discussed that they do not have the required information on emergency removal. Licensee will update this section. Section 12 - LPA reviewed section with Licensee and discussed violations of Title 22. LPA also discussed inconsistencies from Section 8. Section 13 to 15 - LPA reviewed this section with Licensee and discussed adding more detail to this section. Licensee will define "out of control" behavior. Section 18 - LPA reviewed this section with Licensee and discussed how there are inconsistencies from section 8 of program statement. Licensee will update this section. Section 19 - LPA reviewed this section with Licensee and discussed inconsistencies from section 8 of program statement. Licensee will update this section. Section 21 - Licensee will add names and classifications to this section. Section 22 - Licensee will provide resumes and add how long Program Administrator will be on cite. Section 23 - Licensee will ensure qualifications and duties are accurate and added to all job descriptions. Section 24 - LPA reviewed section with Licensee and discussed the list of annual training topics and requirements that were missing. Licensee will review regulations and add missing required training topics. Section 25 - Licensee will add an organizational chart. Section 28 - Licensee will update with a copy of the Facility Sketch. LPA Buchannan offered up the opportunity for discussion and questions and Licensees did not have any more to add. LPA requested that the facility make the required revisions and review their program statement and Licensee will resubmit a hard copy to the department and will not remove original copies. LPA and Licensee agreed that revisions will be submitted on 09/30/2025 and if they are unable to complete them by this time, Licensee will request and extension from LPA Buchannan via email at sarina.buchannan@dss.ca.gov. LPA thanked Licensees for their time and concluded the Office meeting.

met_with: Lorentta Brown, Facility Administrator, Chief Executive Officer Miren Hower


summary: Facility Evaluation

raw_content:
Narrative:
On October 30, 2025, Licensing Program Analyst (LPA) Sarina Buchannan made an unannounced visit for the purpose of initiating a Case Management inspection. LPA met Lornetta Brown, Facility Administrator, who assisted LPA with the inspection. LPA conducted a walk through of the interior and exterior of the facility and no deficiencies were noted. On October 24, 2025, the facility attended a virtual meeting where they informed attendees from Community Care Licensing (CCL) that they had two staff who were not cleared in Guardian but were providing care and supervision to clients in care. A review of the facility's Guardian Roster showed that Staff 1 (S1) was hired on October 13, 2022, but was not cleared and associated until October 25, 2025. Also, Staff 2 (S2) was hired on March 10, 2025, but was not cleared and associated to the facility until October 27, 2025. Based on interview and record review it was confirmed that there were two staff providing care and supervision without a criminal record clearance. Due to this, the facility is being issued a Type A citation for Criminal Record Clearance (See LIC 809D), and a Civil Penalty has been assessed for $500 per staff which is a total of $1,000. This case management is closed. Exit interview conducted, copy of this report, civil penalty, and the Appeal Rights were discussed and provided to Lornetta Brown, Facility Administrator during today's inspection.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced 2-year required inspection was conducted by Licensing Program Analysts (LPAs) Tana Kinder and Stephanie Lor on 12/01/2021 at 11am. LPA Kinder confirmed prior to the inspection that no staff or clients were experiencing health symptoms related to Covid19. Criminal record clearances were reviewed, and the facility is in compliance. There are 31 people associated to the license. The licensing fees are current. Community Care Licensing file, unusual incident reports, facility roster, facility profile and complaint history were reviewed prior to inspecting the facility. The licensing fees are current. The Youth Homelessness Prevention Center is licensed for 6 youth and has 1 youth currently placed. There are 10 staff members currently working at the facility. LPAs reviewed 5 staff files. Files reviewed were not complete and up to date with current documentation. Staff files reviewed have required education, and but were missing current CPR training cards, fingerprint clearance and CDLs. 1 random child file was also reviewed. Documentation included emergency contact information, date of placement and personal rights. The chart was complete. The facility was inspected jointly with LPAs and program manager, Lornetta Brown. A copy of the license, personal rights and emergency exit plan are prominently posted. Client and staff files are in locked cabinets, located in the office. Smoke detectors are in working order, there is a carbon monoxide monitor located in the hallway. Continue... A fully charged fire extinguisher is located in the kitchen. There are 3 bedrooms with 2 beds in each bedroom. Each client is provided with a bed, dresser space, closet space and a nightstand. There are 2 bathrooms. There is a hall closet with additional linen if needed for the bedroom and the bathroom. The kitchen was accessible by the clients. There was enough perishable/non-perishable food for 1 client to last 3/8 days. There was some food that was left over from the Thanksgiving Holiday that was technically labeled to have expired a matter of days ago and the program manager agreed to discard those food items by the end of the week. LPAs tested the water temperature at multiple faucet locations and none of them provided a hot water reading between 105-120. The program manager will request a repair. LPAs inspected the grounds of facility. There is a back patio area, accessible by the youth. The walkway from the front to the back of the facility was clear. There was a shed in the backyard that had past youth's property that was left behind and seasonal decorations stored. The facility vehicle has current insurance and registration. Title 22 deficiencies were cited on an D page today during the inspection. An exit interview was conducted and discussed with Lornetta Brown, program manager, and a copy of the 2-year inspection report was provided and the appeals process.


state: CT

facility_name: Adelbrook Community Services Benny Drive

summary: Visit conducted on March 17, 2026. Visit covered 12 main areas/topics. No compliance issues identified.

raw_content:
DCF-3034
1/2013 (Revised)
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

NAME OF FACILITY / PROGRAM: Adelbrook/Benny Drive Group Home

 TIME OF VISIT (FROM - TO): Morning visit                       DATE: March 17, 2026

 AGENCY PERSONNEL WHO PARTICIPATED:

Job Title
Clinical Therapist

Areas / Topics covered during visit:

•	Census: The group home had three youths at the facility during the quarterly visit, and the current license bed capacity remains at four.
•	Admissions: There was one new admission in the last quarter.
•	Discharges: There were no discharges in the last quarter.
•	Staff: The group home staff consisted of six full-timers and three per-diem employees.
•	Staff vacancies: The program reported that it has one full-time direct care staff opening.
•	Medication: The program reported that it has seven medication-certified employees, and they can administer medication to residents across all three shifts, seven days a week.
•	Physical plant: A walkthrough of the facility was conducted with the clinician to confirm the group home's compliance with regulatory standards.
•	SIU reports: There were no reports in this quarter.

Corrections implemented as a result of previous visit:
N/A

Recommendations: (The following areas were not identified as regulatory non-compliance, but are recommended to be addressed in order to enhance program functioning)
N/A

Areas of regulatory non-compliance identified during this visit:
N/A

Please submit a plan of correction to address the above referenced areas of non-compliance within 30 days of receipt of this report. The plan of correction must be submitted to the attention of the undersigned at the address listed above.

Penny Woodward, LCSW                                          April 6, 2026
Regulatory Consultant                                                  Date

A COPY OF THIS SUMMARY SHOULD BE SENT TO THE EXECUTIVE DIRECTOR OF THE FACILITY / PROGRAM|

facility_name: Adelbrook/Benny Drive Group Home

visit_time: Morning


facility_name: Adelbrook Community Services, Inc. / Esther GH

summary: Visit conducted on February 18,2026. Visit covered 5 main areas/topics. No compliance issues identified.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM:   Esther House
 TIME OF VISIT (FROM - TO): 2:30 pm                         DATE:    February 18,2026

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Esther House co-supervisors (2)
Esther House Clinician

List of Areas / Topics covered during visit:

•	Discussion of the current census, which is 3, and the LBC for Esther House is 4.

•	Discussion of Esther House's current staffing levels, vacant positions, and hiring activities.

•	Discussion and observations of the 2 Esther House residents who were present at the time of the visit. Both residents reported to be doing well and both appeared well cared for.
•	Discussion and observations with 2 residents who were home At the time of the quarterly visit the residents were still attending their school programs.

•	Inspection of the Esther House physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

Corrective Actions implemented as a result of previous visit:

•	Not applicable.

Areas of regulatory non-compliance identified during this visit:

•	None at the time of this quarterly visit.

Patrick Hughes                                               3/3/26
Regulatory Consultant                                   Date|

facility_name: Esther House

visit_date: February 18,2026


summary: Visit conducted on 11/25/2025. Visit covered 5 main areas/topics. No compliance issues identified.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM:   Esther House
 TIME OF VISIT (FROM - TO): 1:00 pm                         DATE:    11/25/2025

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Esther House co-supervisors (2)
Esther House Clinician

List of Areas / Topics covered during visit:

•	Discussion of the current census, which is 3, and the LBC for Esther House is 4.

•	Discussion of Esther House's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Esther House staff regarding the status the Esther House milieu, the clinical programming, recreational activities.

•	At the time of the quarterly visit the residents were still attending their school programs.

•	Inspection of the Esther House physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

Corrective Actions implemented as a result of previous visit:

•	Not applicable.

Areas of regulatory non-compliance identified during this visit:

•	None at the time of this quarterly visit.

Patrick Hughes                                               11/25/25
Regulatory Consultant                                   Date|


summary: Visit conducted on 9/16/2025. Visit covered 5 main areas/topics. No compliance issues identified.

raw_content:
Department of Children and Families
505 Hudson Street
Hartford, CT 06106

Field Visit Reporting Form

This form is used to summarize field visits to a licensed facility or program other than the bi-annual licensing inspection. The visit may be announced or unannounced and is intended to highlight the specific items reviewed / discussed and indicate if there are specific areas where corrective action has been taken or must be taken.

 NAME OF FACILITY / PROGRAM:   Esther House
 TIME OF VISIT (FROM - TO): 1:00 pm                         DATE:    9/16/2025

AGENCY PERSONNEL WHO PARTICIPATED:
Job Title
Esther House Direct Care Worker
Esther House Clinician

List of Areas / Topics covered during visit:

•	Discussion of the current census, which is 3, and the LBC for Esther House is 4.

•	Discussion of Esther House's current staffing levels, vacant positions, and hiring activities.

•	Discussion with Esther House staff regarding the status the Esther House milieu, the clinical programming, recreational activities.

•	At the time of the quarterly visit the residents were still attending their school programs.

•	Inspection of the Esther House physical plant to assess the cleanliness of the home, as well as to ensure there are no health or safety concerns.

Corrective Actions implemented as a result of previous visit:

•	Not applicable.

Areas of regulatory non-compliance identified during this visit:

•	None at the time of this quarterly visit.

Patrick Hughes                                               9/18/25
Regulatory Consultant                                   Date|


facility_name: Adelbrook Community Services, Inc./ Isaiah / GH

raw_content:
March 5, 2026

Alyssa Goduti, Adelbrook President and CEO
60 Hicksville Road
Cromwell, CT 06416

RE: CCF# 79   Isaiah House

Dear Ms. Goduti,

We conducted a relicensing visit of your agency's program on February 18th and 19th, 2026. This inspection determined your agency's program is in compliance with the Regulations for the Operation of Child Caring Agencies and Facilities; Sections 17a-145-48 through 17a-145-98, as well as DCF Guidelines for the Administration of Medication by Certified Staff.
The Department has determined that your agency has met the requirements for a regular license. This license is effective as of April 18, 2026, and is valid for twenty-four months. We thank you and your staff for your cooperative participation in the review process.

Sincerely,
Patrick Hughes

Patrick Hughes
Regulatory Consultant
Department of Children and Families
(p) 860-550-6552
(c) 860-716-2199
patrick.hughes@ct.gov|

report_type: unstructured