summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) T. Davis went to Haynes Family of Programs on March 20, 2025 at 11:50am for the purposes of a Random Annual inspection. LPA met with Michael Miller, Sr. Director of Residential Programs, Jazmin Roybal, Quality Assurance Coordinator, and Nicolas Galarza, Residential Unit Manager, and toured the facility. The group home is located in a residential neighborhood and currently has six youth in placement. During the inspection, LPA observed six bedrooms in the residential cottage (Gatchell). Each bedroom has two twin beds, desks, and closet space. LPA observed fully charged fire extinguishers throughout the facility. Overall, the facility appeared clean, safe, and well maintained. Smoke alarms were operable throughout the facility. LPA observed two bathrooms in good repair and working order. A menu was posted showing the meals scheduled for each day. Exit signs were visible as well inside the facility. LPA also observed a bulletin board that contained Personal Rights information, facility license, Evacuation Plan, facility sketch, and information for Poison Control. There is a screened inoperable fireplace in the living room/dining area. There is adequate space in the living room area. Sharp knives, medications and cleaning supplies are kept locked in areas inaccessible to children. The kitchen was clean and had ample food supply. LPA observed a fully stocked refrigerator and perishable and nonperishable food supply. LPA also observed a game room for the clients' use. There are outdoor cameras on the premises as well as in the common areas of the clients' cottage. The facility has two vans for client transportation needs. The last fire drill occurred on December 28, 2024 at 9:43am. LPA observed a secured in-ground swimming pool on the premises enclosed with a self-latching gate. The Sr. Director of Residential Programs stated that there weren't any firearms or other weapons on the premises. LPA obtained a copy of the minutes relating to the most recent Board of Director's meeting that was held on January 30, 2025. LPA reviewed files and found the reviewed files to be in order. LPA also obtained a client roster and an updated LIC500 (Personnel Report) LPA found no Title 22/ILS deficiencies on this date. Exit interview done LPA discussed the warm weather conditions and precautions with licensee and provided licensee with the department's website address (www.ccld.ca.gov).


state: CA

facility_name: HAYNES FAMILY OF PROGRAMS

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) T. Davis went to Haynes Family of Programs for the purposes of following up on a Special Incident Report (SIR) that was received by Community Care Licensing (CCL) on March 14, 2025. LPA met with Michael Miller, Sr. Director of Residential Programs, Jazmin Roybal, Quality Assurance Coordinator, and Nicolas Galarza, Residential Unit Manager, and discussed the incident. The incident report stated that client #1 (see Confidential Names form (LIC 811) dated March 20, 2025) was allegedly handed an object by staff #1 (LIC 811) that appeared to have some kind of light. Information obtained shows that the incident occurred at the facility on March 12, 2025 at approximately 2:40am. Staff #1 was on duty at the time and sat in a chair in the hallway when client #1 approached him. Information obtained shows that the client and staff engaged in a close-up conversation and the staff handed the client an unidentified object. The client took the item and placed it in his pocket and then went into the living room area for a brief time. The client then placed the item towards his mouth area and the object proceeded to illuminate. The client returned to the area where the staff was and handed the item in question back to the staff. The investigation revealed that the staff was placed on administrative leave pending the outcome of an investigation. The investigation also revealed that the item in question was a vape pen. The client admitted that the item was a vape pen. The staff did not appear for meetings and/or discussions regarding the matter. Based on information and facts obtained in this matter, the Department finds that the facility has ended their relationship with staff #1 and terminated his employment with the facility. The client cooperated in the investigation and is doing fine. The situation has been stabilized and no further follow up is needed. Exit interview done

report_type: Facility Evaluation

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) T. Davis went to Haynes Family of Programs on February 12, 2026 at 11:58am for the purposes of a Random Annual inspection. LPA met with Michael Miller, Sr. Director of Residential Programs, and toured the facility. The group home is located in a residential neighborhood and currently has four youth in placement. The residential cottage (Gatchell) has six bedrooms, two bathrooms, kitchen, dining area, and living room. The facility is licensed to serve twelve clients ages 7-17 years old. There is adequate perishable and nonperishable food supply at the facility. All six bedrooms contained two twin beds, dressers, and closet space. There is an in-ground swimming pool on the premises enclosed with a six foot self-latching gate. LPA observed two bathrooms in good repair and working order. Exit signs were posted throughout the facility. LPA interviewed one client that was present during the inspection. The client appeared neat and well groomed. Sharp knives, cleaning supplies, and medications are kept locked in areas inaccessible to clients. There is adequate seating in the living room and dining areas. The overall campus was observed to be free of debris and hazards. Smoke alarms were operable throughout the facility. The Sr. Director of Residential Programs stated that there were no guns or weapons at the facility. The last fire drill occurred on February 04, 2026 at 3:10pm. There are outdoor cameras on the premises as well as in the common areas. LPA reviewed all four client files and five staff files, respectively. The files were found to be in order. LPA was able to obtain an updated LIC500 (Personnel Report) and a client roster. LPA also obtained a copy of licensee's most recent Board of Director's meeting minutes dated November 20, 2025. LPA found no Title 22 deficiencies on this date. Exit interview conducted.

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) T. Davis went to Haynes Family of Programs for the purposes of concluding the follow up on a Special Incident Report (SIR) that was submitted to Community Care Licensing (CCL). LPA met with Michael Miller, Sr. Director of Residential Programs, and discussed the incident. The incident report stated that client #1 (see Confidential Names form (LIC 811) dated February 12, 2026) was administered the wrong medication. Information shows that child #1 was administered 20 mg of Zyprexa in error during evening medication time. Evidence shows that no other medications were distributed to the child and there were no side effects as a result of the medication error. The facility contacted the Poison Control line and was advised that they should continue monitoring child #1 throughout the night for possible side effects as a result of the error. The child displayed no side effects and indicated that there weren't any changes as it relates to how they felt. Based on information and facts obtained in this matter, the Department has determined that staff failed to perform their duties as assigned which resulted in child #1 being administered the incorrect medication. Therefore, the facility will be cited under section 80075(b)(5)(B) per California Code of Regulations, Title 22: (see LIC809D). Exit interview done


facility_name: HAYNES HOUSE RESIDENTIAL

summary: Facility Evaluation

raw_content:
Narrative:
On the date above a pre licensing visit was conducted at Haynes House Residential by Licensing Program analyst (LPA) Les Inouye. I was met by Licensee Cherrelle Haynes. A discussion on the required documents took place and all forms requested were received and reviewed. A review of the Physical Plant was conducted including the Indoor Activity Space, Fixtures Furniture Equipment and Supplies and Outdoor Activity Space. Kitchen was clean and non-perishable items were observed in the kitchen and additional non-perishable items were observed in the pantry. Bedrooms were observed, 2 single occupancy and double occupancy for a capacity of four. All rooms were appropriately furnished with additional linens was observed. The indoor activity space was observed in a converted garage. All chemicals and cleaning supplies were locked and secured. Smoke Alarms and Carbon Monoxide detectors were observed and operating. Hot water temperature was measured at 115 degrees. Back yard -there is no pool or hot tub, yard consisted of a lawn area with gravel side yards. No staff are hired at this time. The physical plant review was observed to be clean, safe, and free of hazards. At this time the applicant is in the process to be set up with Guardian. Applicant will notify LPA when approved. At this time Regional Center Program Design is being reviewed and Applicant will notify LPA when approved. A final Review by CCL will be completed and LPA will notify Applicant of any updates or approval of license.

visit_type: Prelicensing

met_with: Cherrelle Haynes


facility_name: HEARTWOOD RESIDENCES

summary: Facility Evaluation

raw_content:
Narrative:
On 02/10/2026, Licensing Program Analyst (LPA) Cole Oliver and Licensing Program Manager (LPM) Carolyn Flynn met with Applicant Heartwood Residences for the scheduled Component II face-to-face meeting. Representing the Applicant were Licensee Claudio Arnante, Co-licensee Allan Baldedara, and Marina Suriao. During the meeting, the following topics were discussed: Application process overview Goal and purpose of the facility Basic services and planned activities Needs and services plans Care and supervision policies Emergency intervention policies Emergency disaster procedures Reporting requirements Background clearance/Guardian process At the conclusion of the meeting, the LPA discussed that the pre-licensing inspection will be scheduled once Claudio Arnante and Allan Baldedara are associated with and cleared on a Guardian roster. The LPA thanked the Applicant representatives for attending the meeting. A copy of this report was provided to the Applicant representatives.

met_with: Claudio Arnante , Allan Baldedara


summary: Facility Evaluation

raw_content:
Narrative:
On 04/22/2026 at 9: AM, Licensing Program Analysts (LPA) Cole Oliver and Amee Li met with Administrator Claude Arnante, Allan Baledara, and Mary Fumar and for a scheduled pre-licensing inspection. Using the CARE Inspection Tool, LPAs toured the facility site and grounds. The facility is a single-story house in a residential neighborhood. The house is set up with two single-occupancy bedrooms, one shared bathroom, and a master double-occupancy bedroom which has a connected bathroom with a tub and shower. Currently one room is set up as a staff office. The medications will be stored in a locked kitchen cabinet with the first aid kit. Sharps are in a locked kitchen cabinet to the right of the sink. There were two days of non-perishable foods. The facility has one dining area, a laundry room, and a two car garage. There are multiple closets and cabinets throughout the facility for storage of linens and other facility supplies. Water temperature reached 116. F which is in range. The facility has a thermostat that was set to 68. F. The facility has a video camera set up outside the garage and Ring camera, both are currently not recording. The facility will have parts of the backyard concreted as contracted with the placement agency. The facility has no open bodies of water. Based on this inspection, the facility will be ready for licensure. A copy of this report was provided to Administrator, Claudio Arnante whose signature confirms receipt.

met_with: Administrator, Claudio Arnante


facility_name: HEIWA HOUSE

summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Isabel Mendoza conducted a follow-up complaint inspection to the facility and met with Facility Manager Melinda Kaklia and Beth Toco. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the course of investigating, LPA Mendoza interviewed staff members, clients, and reviewed documentation. The interviews and documentation revealed inconsistencies in explanations that staff caused injury to (C1) (see Confidential Names form (LIC 811), dated {November, 04, 2021}) while in care. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that facility staff caused injury to C1 while in care. Therefore, the above allegation is Unsubstantiated. No deficiencies were cited. Exit interview conducted and a copy of the report was left with the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: Isabel Mendoza LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

report_type: Complaint Investigation

met_with: Beth Toco and Melinda Kaklia

complaint_status: unsubstantiated


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Isabel Mendoza conducted a follow-up complaint inspection to the facility and met with Facility Managers Melinda Kaklia and Beth Toco. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the course of investigating, LPA Mendoza interviewed staff members, clients, and reviewed documentation. The interviews and documentation revealed inconsistencies in explanations that staff threatened (C1) (see Confidential Names form (LIC 811), dated {November, 04, 2021}) and staff did not prevent (C1) from being bullied. Based on interviews and documentation, (C1) had a history of threatening and being aggressive towards clients and staff, and would make mean remarks to clients and staff. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that facility staff caused injury to C1 while in care, and staff did not prevent (C1) from being bullied. Therefore, the above allegation is Unsubstantiated. No deficiencies were cited. Exit interview conducted and a copy of the report was left with the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: Isabel Mendoza LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Isabel Mendoza conducted a follow-up complaint inspection to the facility and met with staff Melinda Kaklia. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the coarse of the investigation, LPA Mendoza interviewed staff, clients, and reviewed documentation. On 11/4/ LPA Mendoza inspected the backyard and found several cigeratte buds throughout the facility backyard. The facility was unable to confirm who they belonged too or knew who smoked on the premises. Based on the information obtained, there is a preponderance of the evidence to prove that minor has access to cigarettes. Therefore, the above allegation is substantiated. Appeal Rights were provided and discussed with the facility and deficiencies were cited. Exit interview conducted and a copy of the report was left with the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: Isabel Mendoza LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, TRAEGER AVE., SUITE FACILITY NAME: HEIWA HOUSEFACILITY NUMBER: 015650006

met_with: Facility Manager Melinda Kaklia


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Isabel Mendoza conducted a follow-up complaint inspection to the facility and met with Facility Manager Melinda Kaklia. The purpose of the inspection was to deliver the findings for the above complaint allegations. On October 10, 2021, Child #1 (C1) (see Confidential Names form (LIC 811) dated {March, 01, 2022}). arrived at school with an improper haircut. During investigation, it was learned that another youth in the home (C2) attempted to cut (C1) hair with hair clippers unsupervised. Based on interviews and physical evidence, it was determined that there was a lack of supervision which resulted in (C2) cutting (C1's) hair. Also, staff allowed (C2) to keep clippers in his possession in his bedroom. Based on the information obtained, there is a preponderance of the evidence to prove that minor has access to sharp objects. Therefore, the above allegation is substantiated. Appeal Rights were provided and discussed with the facility and deficiencies were cited. Exit interview conducted and a copy of the report was left with the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: Isabel Mendoza LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, TRAEGER AVE., SUITE FACILITY NAME: HEIWA HOUSEFACILITY NUMBER: 015650006


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Based on LPA's interviews with staff and record review(s), the preponderance of evidence standard has been met, therefore the above allegations, facility does not supervise visits and ensure that minor has transportation back to the facility after visits is found to be SUBSTANTIATED. Facility is being cited for violation of California Code of Regulations (CCR), Title 22, Division 6 & Chapter 1: 80022(k): Plan Of Operation and 80078(a) Responsibility for providing care and supervision. Please refer to attached 9099D. Two deficiencies were cited today. An exit interview was conducted, appeal rights provided and discussed, and a copy of this report was given to Melinda Kakalia, Facility Manager.

Investigation Findings:
13On 6/21/2022 at 10: AM, Licensing Program Analyst (LPA) Alyssa Ng conducted a complaint inspection at Heiwa House and spoke with Melinda Kakalia, Facility Manager (FM). The purpose of the inspection was to deliver the findings for the above complaint allegations. During investigation, shift logs and client files were reviewed, and it was determined that, staff at the facility does not supervise visits or ensure that minor has transportation back to the facility after visits. Based on a review of the facilities Program Statement under Transportation, it says, "Residents will be transported to and from social, recreational, and religious activities in the program vehicle". In the description of consumer service section of the Program Statement, it says that they provide "Basis General Services and Personal Services". On the Basis General Services, it says that the facility will "Plan, arrange and/ or provide transportation for home/day passes." During confidential interviews, it was confirmed that the facility was not providing transportation to and from home visits. It was disclosed that minor in care uses uber to get to and from monthly visits with their family. Since facility staff do not transport minor to his monthly visits, they do not supervise minor to ensure they are safe. ------Cont. ON 9099C----- SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Alyssa Ng LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, TRAEGER AVE., SUITE FACILITY NAME: HEIWA HOUSEFACILITY NUMBER: VISIT DATE: 06/21/2022

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

met_with: Melinda Kakalia

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
LPA also observed client's head to have some bald spots and dry lips. LPA asked staff how often the client's hair is washed and what hairbrush they were using. Staff stated every day and showed LPA a wet brush comb used for straight hair. LPA suggested to not wash client's hair everyday so that their hair can produce natural oils needed for the scalp and suggested they use a bristle brush. LPA Ng did a file review and confirmed there was no notification or incident report sent into the department. Confidential interviews were conducted and revealed that wound was not covered when attending school, teacher was not notified, and staff were aware of the injury but did not submit incident report within the permitted time frame. Based on LPA's interview with staff and record review(s), the preponderance of evidence standard has been met, therefore the above allegations, Minor sustained injuries while in care and staff did not properly care for minor's injury is found to be SUBSTANTIATED. Facility is being cited for violation of California Code of Regulations (CCR), Title 22, Division 6 & Chapter 1: 80078(a) Responsibility for Providing Care and Supervision and 80075(a) Health Related Services. Please refer to attached 9099D. Two deficiencies and one technical violation was given. An exit interview was conducted, appeal rights provided and discussed, and a copy of this report was given to Melinda Kakalia, Facility Manager.

Investigation Findings:
13On 6/21/22 at 11: AM, Licensing Program Analyst (LPA) Alyssa Ng conducted a complaint inspection at Heiwa House and spoke with Melinda Kakalia, Facility Manager. The purpose of the inspection was to deliver the findings for the above complaint allegations. During investigation, needs and service plans and incident reports were reviewed, and it was determined that a minor sustained injuries in care and staff did not properly care for minor's injury. During a facility inspection dated 5/18/2022, LPA Ng took pictures of client's arm and surrounding areas when they arrived home from school. LPA also received pictures from witnesses. The observed wound was a one inch in size, vertical on their left arm, and it was a dark red color in the middle and brown scabbing around the wound. Surrounding the wound were healed scrapes. The healed scrapes were circular and had a dark brown tint. During the visit on 5/18/2022, LPA asked staff if she can check to see if there are any injuries on clients arms, staff rolled up the clients sleeve and LPA saw the one-inch wound not covered. -----Cont. ON 9099C------ SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Alyssa Ng LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, TRAEGER AVE., SUITE FACILITY NAME: HEIWA HOUSEFACILITY NUMBER: VISIT DATE: 06/21/2022

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


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Investigation Findings:
13On 12/13/22 at 1: PM, Licensing Program Analyst (LPA) Alyssa Ng conducted a complaint inspection at Heiwa House and spoke with Melinda Kakalia, Facility Manager. The purpose of the inspection was to deliver the findings for the above complaint allegations. During investigation, interviews were conducted, photos obtained, and incident reports were reviewed, and it was determined that Staff is not providing proper supervision to minor's in care and minor sustained injuries while in care. Based on LPA's interview with staff, client, and record review(s), the preponderance of evidence standard has been met, therefore the above allegations, Staff not providing proper supervision to minor's in care is found to be SUBSTANTIATED. Facility is being cited for violation of California Code of Regulations (CCR), Title 22, Division 6 & Chapter 1: 80078(a) Responsibility for Providing Care and Supervision and 80072(a)(3) Personal Rights. Please refer to attached 9099D. At this time, two deficiencies were given. An exit interview was conducted, appeal rights provided and discussed, and a copy of this report was sent to Melinda Kakalia, Facility Manager. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Alyssa Ng LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, TRAEGER AVE., SUITE FACILITY NAME: HEIWA HOUSEFACILITY NUMBER: 015650006

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


raw_content:
Investigation Findings:
13On 5/23/23 at 12: PM, Licensing Program Analyst (LPA) Alyssa Ng conducted a complaint inspection at Heiwa House and spoke with Melinda Kakalia, Facility Manager. The purpose of the inspection was to deliver the findings for the above complaint allegation. During investigation, interviews were conducted, photos obtained, and incident reports were reviewed, and it was determined that minor did not recieve a black eye due to staff neglect. Although, the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that minor received a black eye to staff neglect. Therefore, the above allegations are unsubstantiated. At this time, no deficiencies were given. An exit interview was conducted, appeal rights provided and discussed, and a copy of this report was sent to Melinda Kakalia, Facility Manager. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Alyssa Ng LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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


raw_content:
Investigation Findings:
13On 5/10/2023 at 9:40AM, Licensing Program Analyst (LPA) Shikya Belfield and LPA Kristin Pierotti, conducted an unannounced visit to the above facility. The purpose of this inspection was to inform the facility representative of the findings of the above complaint allegation. LPA's met with staff Mark Malong who assisted with the inspection. This investigation was conducted by the investigations bureau (IB). Based on the investigation conducted, the preponderance of the evidence was not met and the allegation of violation of personal rights is Unsubstantiated. An exit interview was conducted and a copy of this report was left with staff Mark Malong. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Mark Malong


raw_content:
Investigation Findings:
13On 5/10/2024 at 9:40AM, Licensing Program Analyst (LPA) Shikya Belfield and LPA Kristin Pierotti, conducted an unannounced visit to the above facility. The purpose of this inspection was to inform the facility representative of the findings of the above complaint allegation. LPA's met with staff Mark Malong who assisted with the inspection. This investigation was conducted by the investigations bureau (IB). Based on the investigation conducted, the preponderance of the evidence was not met and the allegation of violation of personal rights is Unsubstantiated. An exit interview was conducted and a copy of this report was left with staff Mark Malong. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Shikya Belfield LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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


summary: Facility Evaluation

raw_content:
Narrative:
On Wednesday December 15, Licensing Program Analysts (LPA) Isabel Mendoza made an unannounced inspection to conduct an annual required inspection. LPA met with House Managers Beth Toco and Melinda Kaklia. The facility has a census of four clients. There was one client in care (C1), please refer to LIC 811, dated 12/15/21 for confidential names. (C1) was not feeling well. LPA was unable to interview youth because youth is non-verbal. However, client appeared to be in good spirit. Later in the inspection, all other clients arrived, and LPA interviewed (C2). LPA also interviewed one staff. At 1: PM LPA Mendoza toured the facility. The facility is clean, safe and sanitary and in good repair. All passageways are unobstructed. There are no pools or bodies of water. All disinfectants, cleaning solutions and poisons are locked in the garage. Per House Manager there are no firearms in the facility. The inspected bedrooms were furnished accordingly. The kitchen is clean and sanitary. The water temperature measured 110 degrees. The facility has sufficient two day perishable and seven day nonperishable food supply. LPA toured the outdoor premises and observed the backyard fence having several loose, missing, and broken post. LPA Mendoza was informed that the facility had the fence looked out, however the facility was unable to show any proof or record. At 2: PM LPA requested to see the facilities complaint procedure. The facility was unable to locate this document, and unable to verify the procedure. Medications were inspected and LPA found no issues. Medications are locked away in the staff office. At 2: PM, LPA Mendoza reviewed all 4 client files, and all files were complete. [Please Cont. To Lic 809-c...] At 2: PM LPA Mendoza reviewed 4 staff files and all files were complete and all staff have required training. Staff training hours meet the minimum requirements. The Administrator, Yuka Uno administrator certificate expired on 07/16/2019. It was learned that the Administrator has been in the process of renewing the certificate but due to COVID there has been several delays. The facility will submit proof to LPA Mendoza no later than Friday 12/17/21. LPA Mendoza requested the facility to submit the following documents to LPA Mendoza via email by Wednesday 12/22/21. LIC 500 (Staff Schedule), LIC 610 (Emergency Disaster Plan), LIC 309 (Administrative Organization), and the Administrator certificate for (S1), and an LIC 308 (Designation of Responsibility). Facility cited for violation of California Code of Regulations, Title Division Six, regulation 80087(b) Buildings and Grounds. Also, two advisories are being issued. An exit interview was conducted, and a copy of this report was left with the facility.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Isabel Mendoza on 02/15/22 at 10: AM. During the inspection, LPA Mendoza met with Beth Toco, Assistant Administrator, Melinda Kaklia, Facility Manager and inspected the facility inside and out. LPA reviewed 3 child's records on site at the facility at 10: AM. The facility currently has in placement four children who are part of the child welfare system; however, only three of those children are taking psychotropic medication. (C1-C3), please refer to LIC 811, dated 02/15/22 for confidential names.) LPA reviewed 3 staff personnel files on site at the facility at 1: PM. LPA reviewed all 3 child's psychotropic medications and medication records at 12: PM. LPA interviewed 3 staff on site starting at PM. LPA interviewed 1 of children currently taking psychotropic medication at 3: PM, all other clients are non-verbal and unable to answer or understand interview questions. Therefore, LPA did not interview both clients. LPA conducted exit interview with Beth Toco, Assistant Administrator and Melinda Kaklia, Facility Manager at 3: 45PM. LPA provided the Summary Report to Beth Toco, Assistant Administrator upon completion. Continued on 809-C No deficiencies are being cited at this time. LPA did however, issue a Technical Assistance in regards to P-MAR document maintenance. LPA conducted exit interview and left a copy of the report with the Assistant Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On 10/11/2022 at 10: AM, Licensing Program Analyst (LPA) Alyssa Ng made an unannounced inspection to conduct an annual required inspection. LPA met with Melinda Kakalia, Facility Manager. The facility has a census of 5 clients. All but one client were at school. LPA observed one client in care. Client is non-verbal. LPA Ng observed the client sleeping in their bed. Bed had appropriate bedding and pillows. Staff were responsive to the clients needs and able to provide care and supervision to the client in care. The CARE Inspection Tool was used to conduct the inspection. The facility and grounds are clean, tidy, and free of obstructions. There are no hazards on the premises and no firearms, per Facility Manager. 4 bedrooms are single rooms and 1 bedroom is double-occupancy. All beds have clean linens and mattress pads. There is enough storage for residents' personal belongings. Food is of good quality, within date, and stored properly. First aid kit was observed to be complete. Room temperature was maintained at a comfortable temperature within permitted range. Water temperature measured at 116.5 which is in the permitted range. The backyard is surrounded by a wooden fence. The facility has a centralized AC unit in the side yard which is inaccessible to clients. No bodies of water on the premises. All walkways were free from debris or hazards. All window screens are in good condition. Facility has comfortable furnishings, accommodations, and ample lighting. At 10: AM, LPA observed all client records complete with all of the required documentation. Each client and staff has their own separate folder of all required documents. During a review of a client file, LPA found that one client is 19 years old. LPA Ng asked if client has an Age Exception. Facility Manager stated no. LPA Ng advised to send in a request for an Age Exception by 4: PM today. ----------Cont. ON 809C------ Each psychotropic medication was observed to have its own Psychotropic Medication Administration Record (PMAR), as well as individual Centrally Stored Medication Destruction Records (CSMDR). All medications were consistent with these records. At 11: AM. LPA Ng conducted two staff interviews. Resident and staff records were observed to be complete and the facility in compliance. At this time, no deficiencies were cited. An exit interview was conducted, and a copy of this report was to Facility Manager Melinda Kakalia, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/15/22 at 1: PM, CCL met with Regional Center and listed facility for an Informal Meeting. The meeting was held at North First Street Suite 350, San Jose, CA 95131. The following attended the meeting; CCL: Alyssa Ng - Licensing Program Analyst (LPA) , Carolyn Flynn and Isabel Mendoza - Licensing Program Manager (LPM) Regional Center: Derrick Levingston - Quality Assurance Specialist (QA), Mike Minton - Quality Assurance Supervisor, Kimberly Limato- Case Manager Supervisor Heiwa House: Yuka Ono - Administrator, Melinda Kakalia - Facility Manager, Anthony Montgomery- Manager, Lilabeth Toco -Assistant Administrator Topics that were discussed: Lack of supervision: CCL discussed the pattern of allegations regarding unexplained injuries and the one on one supervision. Reporting requirements: CCL explained the importance of reporting incidences on time. Regional Center discussed missing incident reports. CCL requested all incident reports for the month of November- Present. -----Cont. ON 809C---- Buildings and Grounds: CCL brought up concerns regarding a twin bed for a client who is 6 foot. LPA Ng showed pictures of one of the clients headboard. There is chipping and wooden chips hanging out. Administrator Yuka stated that they have a maintenance person who can do repairs when called. CCL recommended to have a maintenance log. Personal Rights: LPA Ng discussed the concerns of bald spots due to improper brushing and care and wanted to discuss the wooden play structure in the home. Regional Center also had concerns with the supervision and what clients can.are doing inside of the structure unsupervised. Concerns about Administrator: CCL had some concerns regarding the hours of the Administrator. CCL requested to have Administrator present during business hours. A new LIC500 will be sent to CCL that will reflect the hours of the Administrator and will reflect proper supervision with one on one clients. No deficiences were cited. Technical Support Program (TSP) was offered. LPM Carolyn Flynn set the due date for December 23rd 2022 if listed facility wants/needs TSP. The Licensee was also cautioned that if there are continued concerns for similar issues, the licensee could be referred to a Non-Compliance Conference for further action.

met_with: Yuka Ono, Melinda Kakalia, Anthony Mongomery, Lilibeth Toco


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 10/13/2023 at 11: AM, Licensing Program Analyst (LPA) Celeste Aparicio and LPA Alyssa Ng made an unannounced inspection to conduct an annual required inspection. LPA met with Melinda Kakalia, Facility Manager. The facility has a census of 5 clients. All but one client were at school. LPA observed 2 clients in care. Clients are non-verbal. LPA Aparicio observed the clients coming home from school and the other coming home from a picnic. Staff were responsive to the clients needs and able to provide care and supervision to the clients in care. The CARE Tool was used to conduct the inspection. The facility and grounds are clean, tidy, and free of obstructions. There are no hazards on the premises and no firearms. There are 4 bedrooms, 3 are single rooms and 1 bedroom is double-occupancy. All beds have clean linens and mattress pads. There is enough storage for residents' personal belongings. Food is of good quality, within date, and stored properly. First aid kit was observed to be complete. Room temperature was maintained at a comfortable temperature within permitted range. Water temperature measured at 103F which is not in the permitted range. LPA stated that the water temperature needed to be within range 105- 120F. The backyard is surrounded by a wooden fence. The facility has a trampoline in the backyard that is secured with a netted barrier around it for the clients safety. There is a AC unit located on the right side of the yard which is inaccessible to clients. No bodies of water on the premises. All walkways were free from debris or hazards. All window screens are in good condition. Facility has comfortable furnishings, accommodations, and ample lighting. At PM, LPA's observed all client records complete with all of the required documentation. Each client and staff has their own separate folder with all required documents. During the review of client files, LPA's found that all clients did not have updated Needs and Services Plans. During the review, LPA's noticed one client will be turning 18 in a month. LPA advised to send in a request for an Age Exception by the clients 18th birthday. Each psychotropic medication was observed to have its own Psychotropic Medication Administration Record (PMAR), as well as individual Centrally Stored Medication Destruction Records (CSMDR). All medications were consistent with these records. At 3: PM. LPA Aparicio conducted 1 client and two staff interviews. Resident and staff records were observed to be complete and the facility in compliance. Facility cited for California Code 84068.3(a) modifications to Needs and Services Plan. At this time, 1 deficiencies was cited and 2 technical violations were issued. An exit interview was conducted, appeal rights were discussed and a copy of this report was given to Facility Manager Melinda Kakalia, whose signature on this form confirms receipt.

Deficiencies:
84068.3(a): Modifications to Needs and Services Plan

(a) The needs and services plan specified in Section 84068.2 shall be updated at least every six months to determine the following


summary: Facility Evaluation

raw_content:
Narrative:
On 2/1/2024 at 1:30PM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the licensed facility. The purpose of this visit was to conduct the SB Psychotropic Medications inspection. LPA met with Melinda Kakalia, Facility Manager who assisted with the inspection. At the time of the inspection, the facility had a census of six clients. No clients were present in the home at the time of the inspection. There were three clients that met the SB484 inspections criteria. LPA reviewed the client files and centrally stored medication binder for three clients. LPA reviewed five staff files including staff training records. LPA did not observe deficiencies regarding the medications file inspection. LPA conducted three staff interviews. LPA did not interview clients as they were not in the facility. Two of the clients that meet SB484 inspections criteria are non-verbal clients. LPA observed Melinda Kakalia, Facility Manager conduct a pill count. LPA did not observe deficiencies with the medication count. LPA conducted a walk through of the home and observed the locked medication cabinet. LPA did not deserve physical plant deficiencies. LPA will attempt to conduct an interview with the client. LPA conducted an exit interview with Melinda Kakalia, Facility Manager at 3:12PM whose signature confirms the receipt of this document.


summary: Facility Evaluation

raw_content:
Narrative:
On 3/1/2024 at 10:35am, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the licensed facility. The purpose of this visit was to finish the SB484 psychotropic medications inspection. LPA met with Melinda Kakalia. LPA conducted one confidential interview for the psychotropic medications inspection. LPA conducted an exit interview with Melinda Kakalia at 10:53am whose signature confirms the receipt of this document.


summary: Facility Evaluation

raw_content:
Narrative:
On 5/10/2024 at 10: AM, Licensing Program Analyst (LPA) Shikya Belfield and LPA Kristin Pierotti made an unannounced inspection to conduct a case management. During this inspection LPA's met with staff Mark Malong who assisted with the inspection. There was one staff and no clients present during this inspection. LPA's conducted a walk through of the facility with staff Malong. During this walk through, LPA's observed the following: client bedroom number two had a nail in the window edge which prevented it from opening. Client bedroom number three had a nail in the edge of sliding door which prevented it from opening. The flooring in the walkway and in client bedrooms number four were in disrepair. Lastly, during a walk through outside, a wire was observed hanging very low in front of the sliding door which poses a potential risk to clients in care. At this time LPA's believe that the facility would benefit from technical assistance support regarding these issues. Advisories were issued regarding California Code of Regulations, Title 22, Division Six, Sections, 80087(a) Buildings and grounds, An exit interview was conducted a copy of this report was left with staff Mark Malong.


summary: Facility Evaluation

raw_content:
Narrative:
On 2/10/2025 at 10: AM, Licensing Program Analyst's (LPA's) Shikya Belfield and LPA Benjiman Oliver made an unannounced inspection to conduct an annual required continuation inspection at the above facility. LPA's met with Melinda Kakalia, Facility Manager. The facility has a census of 6 clients. All clients were at school during this inspection. Four out of six clients are non-verbal. There were three staff present at the start of this inspection. LPA's conducted a walk through of the facility with facility manager. LPA's observed proper signs posted in the facility and bedrooms of the clients met all requirements outlined in the regulations. During this inspection LPA's reviewed five staff files using the CARE TOOL and interviewed two staff regarding facility operations. Due the restrictions of time, the inspection could not be complete at this time. There were no violations cited during this inspection. An exit interview was conducted and a copy of this report was left with facility manager Melinda Kakali.

met_with: Melinda Kaka


summary: Facility Evaluation

raw_content:
Narrative:
On 11/5/2024 at 9: AM, Licensing Program Analyst's (LPA's) Shikya Belfield and LPA Kristin Peirotti made an unannounced inspection to conduct an annual required inspection at the above facility. LPA's met with Melinda Kakalia, Facility Manager. The facility has a census of 6 clients. All but one client were at school. LPA observed one client in care present at the facility. Four out of six clients are non-verbal. The CARE Tool was used to conduct the inspection. The facility and grounds are clean, tidy, and free of obstructions. There are no hazards on the premises and no firearms. The facility has no bodies of water. There are 4 bedrooms, 3 are single rooms and 1 bedroom is double-occupancy. All beds have clean linens and mattress pads. There is enough storage for residents' personal belongings. Food is of good quality, quantity, within date, and stored properly. First aid kit was observed to be complete. Room temperature was maintained at a comfortable temperature within permitted range. Water temperature measured at 134F which is not in the permitted range and there is no sign posted regarding the temperature. LPA stated that the water temperature needed to be within range 105- 120F or that a sign needs to be posted regarding the temperature. During a review of the staff schedule it was observed that two staff were on the schedule working and are not criminally record cleared to work. Facility cited for violations of the California Code of Regulations Title Division Six, section 80019(e)(2) Criminal record clearance as described on the following page LIC D. During a review of posted forms in the facility it was observed by LPA's the emergency disaster plan was not up to date or signed. A walk through of the facility was conducted and the mirror in the second bathroom was observed to be broken and hanging out of the wall. Several attempts were made by facility manager to contact the administrator and designated person responsible in the absence of administrator and they were not able to reached or come to the facility. At this time the inspection could not be complete and will be completed at a later date. An exit interview was conducted and a copy of this report along with appeal rights was left with facility manager Melinda Kakalia.


summary: Facility Evaluation

raw_content:
Narrative:
On 6/19/2025 at 11: AM, Licensing Program Analyst's (LPA's) Shikya Belfield and LPA Omar Sawyer made an unannounced inspection at the above facility. The purpose of this inspection is to conduct a continuation of the annual required inspection. LPA's met with Melinda Buco, Facility Manager who assisted with the inspection. The facility has 6 clients in care. Four clients were on an outing and two clients were present during this inspection. Four out of six clients are non-verbal. One verbal client was present during this inspection and was interviewed by LPA Sawyer. At 11: AM Program director Anythony Montgomery and Administrator Lilibeth Toco arrived at the facility. During this inspection the CARE TOOL was used. LPA reviewed three client files and plan of operation to conclude the annual inspection. Advisories issued. There were no Violations of California Code of Regulations, Title 22, Division Six, cited during this inspection. An exit interview was conducted and a copy of this report was left with Administrator Lilibeth Toco whose signature confirms receipt.

met_with: Melinda Buco


summary: Facility Evaluation

raw_content:
Narrative:
On 6/19/2025 at 11: AM, Licensing Program Analyst's (LPA's) Shikya Belfield and LPA Omar Sawyer made an unannounced inspection at the above facility. The purpose of this inspection is to conduct a continuation of the annual required inspection. LPA's met with Melinda Buco, Facility Manager who assisted with the inspection. The facility has 6 clients in care. Four clients were on an outing and two clients were present during this inspection. Four out of six clients are non-verbal. One verbal client was present during this inspection and was interviewed by LPA Sawyer. At 11: AM Program director Anythony Montgomery and Administrator Lilibeth Toco arrived at the facility. During this inspection the CARE TOOL was used. LPA reviewed three client files and plan of operation to conclude the annual inspection. Advisories issued. There were no Violations of California Code of Regulations, Title 22, Division Six, cited during this inspection. An exit interview was conducted and a copy of this report was left with Administrator Lilibeth Toco whose signature confirms receipt. Due to technical issues with LPA equipment, this report was sent via email to Administrator Lilibeth Toco and Program Director Anthony Montgomery.


summary: Facility Evaluation

raw_content:
Narrative:
On 6/21/2022 at 11: AM, Licensing Program Analyst (LPA) Alyssa Ng conducted an unannounced case management inspection with Heiwa House and spoke with Melinda Kakalia, Facility Manager. The purpose of the inspection was to follow up on why incident reports are not being submitted within the required reporting requirements. LPA Ng reviewed incident reports that have been sent in by the listed facility and found no incident reports sent to the Department in 2022. LPA Ng advised FM that any behavior or injury is considered an incident and should be documented properly and sent to the department within seven days. LPA reminded FM that it lets CCL know what is happening inside the facility, especially when there are complaints related to the incident. Facility cited for violation of California Code of Regulations, Title 22, Division Six, Section 80061(b)(1)(D) Reporting Requirements. An exit interview was conducted, appeal rights provided, and emailed to Administrator Yuka Ono.


summary: Facility Evaluation

raw_content:
Narrative:
On 2/10/2023 at 1: PM, Licensing Program Analyst (LPA) Shikya Belfield conducted an announced case management inspection to the above facility. The purpose of this inspection is to conduct a Psychotropic Medications Inspection. LPA Belfield met with administrator assistant Lilibeth Toco and facility manager Lelinda Kakalia. At the time of the inspection, two other staff had taken one client on an outing and they returned at the end of the inspection. The facility currently has five clients, two verbal and three non-verbal. The facility currently has four clients that are prescribed psychotropic medications. LPA reviewed two client files, two staff files, and facility files. Review was limited as to not interfere with clients routine. LPA interviewed two staff members while in the facility. While observing the facility and speaking with the facility staff, it was learned that due to clients ripping things off of the wall, the facility no longer had a proper mental health bill of rights and personal rights poster. LPA stated they would provide the link the staff for ordering more posters. There were no issues with the pill count. LPA reviewed the centrally stored medication binder and the Psychotropic Medication Administration Records (PMAR). During a file review there were no training records present in the facility. Medication training was provided for one of the staff however there was no information regarding psychotropic medication. Facility is cited for violation of California Code of Regulations, 84065(i)(3)(M) Personnel Requirements as described on the following page 809D. An exit interview was conducted and a copy of this report along with appeal rights will be sent to administrator Yuko Uno and facility manager Lelinda Kakali and administrator assistant Lilibeth Toco.

met_with: Lilibeth Toco


summary: Facility Evaluation

raw_content:
Narrative:
On 02/12/25 at 10:15am, an unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs)Celeste Aparicio and Kristin Pierotti. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA's Aparicio and Pierotti met with Melinda Kakalia, Facility Manager and inspected the facility inside and out. LPA reviewed 0 children's records and 4 staff personnel files on site at the facility. Upon review of the potential child's file, LPA's determined that the child did not qualify for the inspection due to the child's parents holding the medical rights of the child. LPA reviewed 0 child's psychotropic medications and medication records. LPA interviewed 1 staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 0 children currently prescribed psychotropic medication. During the inspection the LPA observed deficiencies in 4 of 4 staff files reviewed. All reviewed staff files did not meet the required initial and annual psychotropic medication training or present training curriculum. (see attached 809D). LPAs conducted an exit interview, reviewed plans of correction, and discussed appeal rights. LPA's provided a copy of this licensing report to Melinda Kakalia, Facility Manager.

met_with: Facility Manager,Melinda Kakalia


summary: Facility Evaluation

raw_content:
Narrative:
On 01/29/2026 at 12:15 p.m., Licensing Program Analyst (LPA) Brenda Rodriguez conducted an unannounced Annual Inspection and met with Melinda Kakalia, Lead Staff Member. LPA Rodriguez disclosed the purpose of the inspection and was granted entry into the facility by the Administrator. LPA Rodriguez used the CARE Inspection Tool. The facility currently has a census of six clients. LPA Rodriguez reviewed five (5) staff files and three (3) client files. During the physical plant inspection, no deficiencies were found. LPA Rodriguez toured the facility inside and out. All client bedrooms were equipped with comfortable furnishings for clients' belongings and full-sized beds. Client's bathroom was clean and furnished with hygiene supplies for each client. The facility is clean, safe and sanitary. The kitchen was observed to be clean and free of hazards or chemicals. The weekly menu was posted. No bodies of water on the premises. All walkways were free from debris or hazards. LPA toured the backyard and observed it to be free from hazards. At this time, the inspection is not complete. LPA Rodriguez will be back at a later day to complete the required annual inspection. An exit interview was conducted, and a copy of this report was given to Lead Staff Member Melinda Kakalia and Facility Manager Anthony Montgomery, whose signature on this form confirms receipt.

met_with: Melinda Kakalia, Lead Staff Member & Anthony Montgomery, Facility Manager


facility_name: HERITAGE HOME

summary: Facility Evaluation

raw_content:
Narrative:
On Thursday 11/18/21 at 9:46AM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility for a required annual inspection. LPA met with Administrator Alfredo Bonifacio and informed of the purpose of the visit. The CARE Inspection Tool was used to conduct the inspection. The facility and grounds are clean, tidy, and free of obstructions. There are no hazards on the premises and no firearms, per Administrator. Bedrooms are single-occupancy, and beds have clean linens and mattress pads. There is enough storage for residents' personal belongings. Food is of good quality, within date, and stored properly. First aid kit was observed to be complete. Room temperature was maintained at a comfortable temperature within permitted range. Hot water measured within permitted range. LPA conducted confidential staff interviews. Residents are nonverbal but were observed to be content, engaged in activities, clean, and dressed in well-fitting clothing. During staff interviews, some staff were unaware of the need to contact CPS and the police if they witness abuse, or what number to call. Staff have received training on, and signed the acknowledgement forms for, their mandated reporter status, but LPA advises, per California Code of Regulations, Title 22, Section 84065, that staff be re-trained and suggests that a posting of the local child protective services report line number be available where visible to staff. There are no deficiencies cited today. An exit interview was conducted, and a copy of this report was left with Administrator Alfredo Bonifacio, whose signature on this form confirms receipt.

met_with: Administrator Alfredo Bonifacio


facility_name: HERITAGE HOME-LUDMILA WAY

summary: Facility Evaluation

raw_content:
Narrative:
On December 17, 2025 at 1:00 pm, Licensing Program Analyst (LPA) Sarina Buchannan conducted an in person office meeting with Applicant #1, Applicant #2, Employee #1 and Employee #2. The purpose of the meeting was to continue the Group Home application process by conducting the Component II orientation. LPA reviewed the following documentation below with all Applicants. Heritage Home - Ludmila Way Group Home Application - Capacity of Ambulatory children, ages 7-17 years old. Fire Clearance granted on 9/12/ Financial Verification for 3 months was verified on 8/21/ Administrator Certificate for SHEILA RAMIREZ obtained on 06/02/ Application Fees in the amount of 908 were paid on 8/18/ LIC 200 should have signatures from both applicants who completed an LIC 215. LIC 215 for both applicants were missing required information. LIC 308 is missing the facility number. LIC 309 is missing sections II. LIC 401 please submit for other licensed facility LIC 401A part I is blank and some questions in part II were left blank. LIC 500 need Social worker information and signature/date. LIC 501 missing required administrator information and not required for applicants as they completed an LIC 215. (report continued on LIC 809C) LIC 610C needs to add CCL & contact information on Section II. Needs required labels for outdoor areas, electrical shutoffs, and facility exits. Job Descriptions do not have the the correct requirements listed for Facility Administrator qualifications. Guardian is only showing Abigail, Shiela, and Alfredo. First Aid and CPR certification for applicants and all the new staff is needed. Items still Pending: LIC 309 is missing sections II. Please complete this sections with the relevant placement agency information. LIC 401A part I is blank and some questions in part II were left blank. Please add the required information using the relevant business account. Please complete both sections. Job Descriptions for facility administrator need to have the correct qualifications. High school requires three years of supervisory experience providing direct care and supervision to people with disabilities. Potential Administrator needs to attend Component III Orientation. Original Orientation Certificates need to be brought to regional office for signature by LPA. All new New Hires need to be fingerprinted and associated to the facility in Guardian. Please associate Erwin to facility. Upcoming: Component III will be completed on 02/14/26 at 9: AM Pre-Licensing will be conducted on 2/19/26 at 12: PM. Exit interview conducted. A copy of this report was provided to the Applicants.

met_with: Abigail Bagang, Cheif Executive Officer, Sheila Ramirez Facility Administrator, Alfredo Bonifacio Treasurer/Secretary, Erwin Bagang, Office Manager


facility_name: HERITAGE HOME - BROXTON AVE

summary: Facility Evaluation

raw_content:
Narrative:
On March 5, 2025 at 1: PM, LPA Michelle Silvas and LPM Jodean Hall conducted an in person office meeting with Alfredno Bonifacio, Abigail Bagang,Erwin Bagang and Namier Marfino. The purpose of the meeting was to continue the group home application process by conducting the Component II orientation. LPM Jodean Hall explained the purpose of the meeting and obtain copies of the participants driver's licenses. Documents discussed during time of meeting were the following: 1. LIC Documents (LIC309, LIC 401, LIC403, LIC404, LIC501, LIC503, LIC508, LIC610C, LIC999) 2. First Aid & CPR 3. Fire Clearance (STD 850) - Is cleared but LIC 850 has not been submitted to CCL Organization: 4. Role of Erwin Bagang (Office Manager/ facility manager) 5. Administrator (Namier Marfino) 6. Abigail is Secretary and Treasurer. 7. Structure of Board - The board was notified that policy is reviewing and changes may be requested. Office Conference Continued ~ Program Statement- Policy and Procedures discussed during time of meeting were the following: 8. Program description 9. Medical/dental 10. Admission Assessment 11. Discipline Policy 12. Allowances 13. Chores 14. Administration Oversight 15. Staff Qualifications 16. Training 17. Lease Agreement LIC 9106 - Group Home Program Statement will be amended to remove #6 behaviors on page 8. 20. Scheduled pre-licensing for Tuesday, March 25, 2025 at 10:30am 21. Component III will be scheduled for the end of March

met_with: Abigail Bagang and Namier Marfino


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Michelle Silvas and Licensing Program Manager (LPM) Jodean Hall made an announced pre-licensing inspection on 4/1/2025 at 12: PM and met with Alfredo Bonifacio, Licensee, Namier Marfino, Administrator, Abigail Bagang, Licensee, and Erwin Bagang, Office Manager to tour the facility inside and out. At 12:08PM, LPA Silvas and LPM Hall began touring the facility and observed that the facility is ready for licensure. LPA Silvas observed that there are four single occupancy bedrooms, two and a half client bathrooms, a dining area, kitchen, extra room, office area. LPA Silvas observed the front entry way closet will store the medications and client files and will be locked at all times to ensure inaccessibility. There is a fully stocked first aid kit available. Clients personal rights, ombudsman information, facility sketch, menu and planned activities are posted. There is enough seating space in the living room. LPA Silvas observed that there are three fire extinguishers one in the front hallway, garage and in the kitchen area that are accessible and were last serviced on 8/19/24. LPA Silvas observed seven dual carbon monoxide and smoke detectors in two hallways and all bedrooms that are working as required. LPA Silvas observed that there is a two day supply of perishable food and seven day of nonperishable accessible when clients are admitted. LPA Silvas also observed that there are laundry facilities for clients. The outdoor of the facility appears to be safe for clients in care. There is adequate seating space in the backyard. There is a working phone located in the kitchen, receiving room and office area. LPA Silvas advised the facility that they are to notify the Department upon admission of their first client. LPA Silvas also advised that upon acceptance of the last sections of the program statement approval, the Licensee shall submit a final binder of the approved Program Statement to the Department, tabbed and in a binder and turned into LPA by April 8, 2025. LPA Silvas notified the facility that Component III will be scheduled. The mass causality and emergency disaster binder will be completed and proof of this will be sent to LPA vial emailed picture. The front hallway closet door that will store medications will be having a smart lock installed and a picture of this will be emailed to LPA. LPA Silvas and LPM Hall conducted an exit interview and provided a copy of this report to the facility.

met_with: Alfredo Bonifacio, Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On October 23, Licensing Program Analysts (LPAs) Sarina Buchannan and Sara Luman-Gonzalez conducted an unannounced visit to the above facility for the purpose of conducting a post-licensing inspection. LPA met with Namier Mafrino, Facility Administrator, and walk through of the interior and exterior of the facility was conducted. There is one client placed at the facility. During this inspection the physical plant was as follows: Required postings present, License, Accreditation, Personal Rights, Emergency Disaster Plan, and Complaint Hotline. Disinfectants/Cleaning solutions were inaccessible. Menu present and posted, nonperishable foods one week and fresh perishable foods three days minimum. Dining area fully furnished to accommodate clients in placement. Bedrooms have required linens, and furniture is adequate and in good repair. Bathroom toilets, wash basin, and shower fixtures are in good repair, no leaks, and water temperature is between 105-120 degrees Fahrenheit. Soap and paper towels are provided and available to clients. Washer and dryer available and in good repair. The client files are maintained locked. Medication was centrally stored, locked, and inaccessible. Temperature of the facility was between 68 degrees Fahrenheit and a maximum of 85 degrees Fahrenheit. Fire Extinguisher up to date and inspected on April, 2025. Facility is free of vermin and pests. There are three working telephone accessible to clients. Carbon monoxide detectors and smoke detectors are fully functional. The First Aid Kit is fully stocked. There is Toyota Sienna that is properly maintained lights, tires, seat belts, and registration/insurance up to date. (report continued on LIC 809C) Based on a review of the facility's Guardian Roster the staff working during today's inspection are fingerprint cleared and associated to the facility. One technical violation noted (See LIC TV), otherwise facility was observed to be in full compliance. Exit interview was conducted with Namier Mafrino, Facility Administrator, a copy of this report and Appeal Rights were discussed and provided to the licensee.

met_with: Namier Mafrino, Facility Administrator


raw_content:
Narrative:
One interviewee alleged that reading homework was used as discipline and that when the youth refused to complete it and attempted to leave, staff threw a shoe and used force to prevent them from leaving. Three other interviewees stated the allegations were reported to them, however, one shared that the individual who reported it to them later recanted the claims. The remaining six interviewees indicated that staff were following the client's educational plan by implementing nightly reading and were not using it as discipline. These six interviewees also denied that staff have ever hit clients or prevented them from leaving the facility. Additionally, nine out of ten interviewees expressed no concern regarding the allegations or the youth's safety within the facility. Also, LPA confirmed with school staff that nightly reading is standard protocol and was discussed with the client's caregivers prior to the incident. Two school staff members observed the client the day after the alleged incident and reported no visible marks or injuries. Lastly, LPA reviewed facility documentation and found no corroborating evidence or disciplinary records to support the allegations. Due to inconsistent statements, lack of physical evidence, and clarification obtained during interviews, the allegations could not be confirmed. Although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report and Appeal Rights were provided to the licensee.

Investigation Findings:
13On February 5, Licensing Program Analyst (LPA) Sarina Buchannan made an unannounced visit to deliver findings to the above Group Home and met with Erwin Bagang, Office Manager, who assisted LPA with the inspection. A walkthrough was conducted, and no deficiencies were noted. Prior to this meeting, LPA completed a 10-day inspection on November 13, 2025. LPA requested and obtained: shift reports, staff roster and contact information, client roster (LIC 9020), staff schedule, client face sheets, and needs and services plans. LPA conducted ten confidential interviews between November 13, 2025, and February 5, 2026. Based on evidence gathered and confidential interviews conducted, the above allegations could not be substantiated. During the investigation, LPA confirmed that an incident occurred on November 3, 2025, in connection with a reading activity. However, statements from the ten interviews were inconsistent and did not corroborate the allegations. (report continued on LIC 9099C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Connie Goldie LICENSING EVALUATOR NAME: Sarina Buchannan LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: HERITAGE HOME - BROXTON AVEFACILITY NUMBER: VISIT DATE: 02/05/2026

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

met_with: Erwin Bagang, Office Manager


facility_name: HERITAGE HOME II

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

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


raw_content:
Investigation Findings:
13On 9-13-22, 1: PM Licensing Program Analysts (LPA) George Karkazis and Alyssa NG conducted a follow-up complaint inspection at Heritage House II and met with Alfredo Bonafacio, Facility Administrator. The purpose of the inspection was to deliver the findings of the above complaint allegations. During the investigation, LPA Karkazis conducted confidential interviews with staff members. All clients at this facility are nonverbal. Therefore, LPA was unable to interview clients. However, LPA Karkazis conducted interviews with authorized representatives. In addition, LPA Karkazis obtained and reviewed documentation that pertained to the above allegations. On August 11, 2022, there was a staff note stating that (S3) (see Confidential Names form (LIC 811) dated 9/7/2022, was informed by House Manager (S4) that direct care worker (S5) had locked a client in their bedroom using a child safety lock on the outside of his door. Based on interviews, it was learned that the (S5) had difficulty with the client's behavior and made an error in judgment. In addition, LPA obtained a copy of the incident report dated August 18, 2022, mentioning that a direct care worker (S5) used a child safety lock on a client's bedroom door. On August 12, 2022, the staff member was terminated. Based on interviews and physical evidence, it was determined that the Staff locked the minor in the minor's bedroom, and the minor had an inappropriate locking device on the outside of the minor's bedroom door. Based on the information obtained, there is a preponderance of the evidence to prove the above allegations. Therefore, the above allegations are substantiated. Appeal Rights were provided and discussed with the facility, and deficiencies were cited per California Code of Regulations, Title 22, Section 84072(14) Personal Rights. An exit interview was conducted, and a copy of this report was left with Alfred Bonafacio. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Mendoza LICENSING EVALUATOR NAME: George Karkazis LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CENTRAL COAST SC/RES, TRAEGER AVE., SUITE FACILITY NAME: HERITAGE HOME IIFACILITY NUMBER: 075650138

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


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On Friday 5/13/22 at 9:17AM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility for a required annual inspection. LPA met with Administrator/Licensee Alfredo Bonifacio and informed of the purpose of visit. Safety precautions were taken, including mask-wearing and pre-visit screening call. LPA used the CARE Inspection Tool to conduct the inspection. The facility is a single-story house in a residential neighborhood. There are 4 resident bedrooms and 3 bathrooms. All rooms are single-occupancy, and all beds have clean linens. There are no hazards or bodies of water. There are no firearms on the premises, per Administrator/Licensee. Chemicals are stored in a locked cabinet in the kitchen, sharps are stored in a locked drawer in the kitchen, and medications are stored in a locked cabinet in the kitchen. The kitchen is stocked with food in the quantity and quality to meet the needs of residents in care, and food is stored properly. There are four residents in care, and one is present during visit. All residents are nonverbal. The following deficiencies were found. See attached LIC 809-Ds and LIC 9102s. - Resident R1's (See LIC Confidential Names) medication administration record (MAR) was not consistent with medication label. Medication Risperidone label reads "Take 3 and one-half tablet," and the MAR reads "4 tabs." There is a conservator-signed psychotropic medication consent form dated 7/30/21 that authorizes 4 tablet dosage. The quarterly report indicates 4 tablets as well. LPA is issuing an advisory of California Code of Regulations (CCR), Title 22, Section Health Related Services. - Resident R2 and R3 have no psychotropic medication consent form. R4's form is signed but has no medication listed. LPA is issuing a citation of CCR, Title 22, Section Children's Records. - All youth have psychotropic medication. Psychotropic medications are not logged on separate log using LIC 622B or version of the form with all required sections. LPA issued a citation of CCR, Title 22, Section Children's Records. - Resident R1 needs and services plan, or behavior/treatment plan, dated 4/30/22 is only signed by the administrator and was not developed by Regional Center. There is no plan dated within the last 6 months that is signed by authorized representative. LPA is issuing a citation of CCR, Title 22, Section 84068. Needs and Services Plan. - Residents R2, R3, and R4's needs and services plans, or behavior/treatment plans, are older than 6 months. LPA is issuing a citation of CCR, Title 22, Section 84068. Modifications to Needs and Services Plan. - Staff training hours meet requirements, but annual training record for 2021 does not indicate all staff attended a training on psychotropic medications. LPA is issuing an advisory of CCR, Title 22, Section Personnel Requirements. - Staff S1 and S2 (See LIC 811) are not listed on the Guardian roster printed this morning. However, there are state-issued clearance letters for this facility in each staff member's file. LPA connected to Guardian during visit, and there was no clear indication of any changes to their clearances or listing on rosters. LPA is issuing an advisory of Criminal Record Clearance. An exit interview was conducted, appeal rights provided, and a copy of this report provided to Administrator/Licensee Alfredo Bonifacio, whose signature on this form confirms receipt.

Deficiencies:
84068.3(a): Modifications to Needs and Services Plan

(a) The needs and services plan specified in Section 84068.2 shall be updated at least every six months to determine the following


summary: Facility Evaluation

raw_content:
Narrative:
On 4/18/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a visit at the facility for a required annual inspection. LPA met with Administrator Alfredo Bonifacio and informed of the purpose of the visit. There are four residents in care, and three are expected to return around 3:30PM-4PM. LPA observed three residents in care. LPA toured the facility and inspected 5 personnel files and discussed with Administrator. During the facility tour, LPA observed the facility to be clean and tidy with sanitary kitchen and bathrooms. Knives and medications were locked away and inaccessible to residents. No hazards were observed. A visit will be conducted on a later date to complete this inspection. During today's portion of the inspection, LPA observed the following: 1) The files for two staff, S1 and S2 (see attached LIC Confidential Names List), had incomplete initial training records that did not reflect the full amount of hours were obtained. LPA is issuing a citation of California Code of Regulations, Title 22, Section 84065. See attached LIC 809-D. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 7/6/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted an annual continuation inspection at the facility. LPA met with Assistant Administrator Natasha Lovell and informed of the purpose of the visit. During the inspection, LPA reviewed resident records and conducted interviews with staff and observations of residents. LPA observed the facility to be clean, tidy, and in sanitary condition. Staff engaged well with residents, and residents appear comfortable in the facility and around the staff. Residents were observed to have hygiene needs met and to have clean, well-fitting clothes. A menu was posted. Personal rights posters are posted. LPA inspected resident files and observed them to be complete. LPA advises that grievance procedures should be posted in the facility where visible to residents and residents' authorized representatives. There are no citations. An exit interview was conducted, appeal rights discussed, and a copy of this report left with Assistant Administrator Natasha Lovell, whose signature on this form confirms receipt.

met_with: Assistant Administrator Natasha Lovell


summary: Facility Evaluation

raw_content:
Narrative:
On 6/5/2024 at 10:06am, Licensing Program Analyst (LPA) Selena Hood and LPA Kristin Pierotti conducted an unannounced visit to the listed facility. The purpose of this visit was to conduct the required annual inspection. LPAs met with Reggie Lanuza, Direct Support Personnel. At 10:35am, LPAs met with Alfredo Bonifacio, Administrator. The facility currently has a census of four clients. At the time of the inspection, three staff members and two clients were present. During the inspection, the staff members and clients left to an outing. LPAs reviewed the client files for four clients in care. LPAs observed that four clients were missing signatures on their discharge procedures. LPAs delivered a Technical Assistance for 84070(c)(2). LPAs observed no other deficiencies with the client files. LPAs did not conduct client interviews because all clients in care are non-verbal. LPAs reviewed staff files for five staff members. LPAs did not observe deficiencies in the staff files. LPAs reviewed emergency binder, centrally stored medication log, posted emergency information, staff schedule, menu, behavioral binders, and daily log binders. LPAs conducted one staff interview. LPAs conducted a walk-through of the facility and observed the physical plant. LPAs observed that each room had a dresser with clothes, a bed with sheets and bedspreads, and a sufficient amount of room. Each client currently has their own room. LPAs observed the sharps, cleaning supplies, and hygiene supplies to be locked. LPAs observed the files and medication to be in a locked cabinet. LPAs observed that there was a sufficient amount of perishable and non-perishable items. The home was clean, tidy, and in good repair. LPAs conducted an exit interview with Alfredo Bonifacio, Administrator at 12:52pm whose signature confirms the receipt of this document.

met_with: Alfredo Bonifacio


summary: Facility Evaluation

raw_content:
Narrative:
On 05/01/25 at 11:15am, Licensing Program Analyst (LPA) Kristin Pierotti conducted an unannounced required annual inspection at the facility. LPA met with Alfredo Bonifacio, Facility Administrator and informed of the purpose of the visit. The facility currently has 4 clients in care. LPA used the CARE Inspection Tool and conducted a tour of the facility site, review of 6 personnel records and 4 resident records, and confidential interviews with 2 staff members and 0 residents. Residents are nonverbal. LPA observed the facility to be in good condition, clean and well organized. Kitchen and bathrooms are sanitary. The bedrooms contain individual beds for clients and plenty of storage for personal items. The rooms and common spaces are nicely decorated and furnished. Medications, sharps, and chemicals are stored where inaccessible to the residents. LPA reviewed 6 personnel records. Staff have valid intervention and first aid training certifications, and have completed their annual training hours. During personnel record review, LPA observed that S6 does not have background clearance. LPA informed licensee about the need to remove the staff from the premises. LPA reviewed 4 resident records. Residents' records contain current emergency contact information, complete care plans, accurate medication records and cash records. During resident record review, LPA observed C1 to be 18 years of age and does not have an approved age exception. Based on interviews, LPA observed staff to be knowledgeable of facility policies, mandated reporting, and intervention procedures. LPA identified one area in which there was a Technical Violation. (See associated LIC9102 form). LPA is issuing a citation of California Code of Regulations (CCR), Title 22, Sections 80019(e) Criminal Record Clearance. Additionally, as mandated in Section 80019(g), LPA is assessing an immediate civil penalty of $100 for a maximum of 5 days in violation in which S1 worked on site, for a total of $500. See attached LIC 421BG. An exit interview was conducted, appeal rights discussed and a copy of this report, LIC421BG and the LIC9102 were left with Alfredo Bonifacio, Facility Administrator whose signature confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 8/22/22 at 11:45AM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to deliver notice of a deficiency found during an investigation at the facility. LPA met with Administrator Alfredo Bonifacio and informed of the purpose of the visit. During the investigation, it was learned that a nonverbal resident had sustained bruising on the lower abdomen. Staff observed light redness in the morning when staff noticed that the resident had toy cars in their diaper. The redness progressed to bruising. This incident was documented in facility records but there is no documentation that it was reported to the authorized representative as required until the authorized representative asked the facility about the bruises during a home visit. LPA is issuing a citation per California Code of Regulations, Section 80061. See attached LIC 809-D. Per administrator, the resident has thin skin, and the facility has updated their policy of writing incident reports for this resident where any time redness is observed, since it is more likely for this resident to progress to bruising, the facility will generate incident reports. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Alfredo Bonifacio, whose signature on this form confirms receipt.


facility_name: HERITAGE HOME MT ISABEL

summary: Facility Evaluation

raw_content:
Narrative:
On November 20, 2022 at 12:00pm, Licensing Program Analyst (LPA) Monica Pavia conducted an announced pre-licensing inspection of the facility. LPA met and toured the facility with Administrator, Alfredo Bonifacio, Licensee, Marisa Ferolino, and Administrator in Training, Natasha Lovell. This Group Home is a two story facility located in a residential area. The facility consists of 4 client bedrooms and 2 client bathrooms, living and dining areas, kitchen, and laundry room. The facility is clean, safe, sanitary, and in good repair. All passageways are unobstructed and all doors open freely. There is no pool on the facility premises. Fire arms are not allowed on the facility premises. At the time of visit, the following was observed: Fire extinguishers are throughout the house. Smoke detectors are throughout the house and operational. Carbon monoxide detectors are located in the hallway, outside of the client bedrooms. Each bedroom has a bed, clean linens, and adequate drawer/cabinet space. Facility has a fire clearance. First aid kit was observed. Hot water temperature measured at 108 degrees Fahrenheit. Staff and client records will be kept locked in a cabinet. Medications will be centrally stored and locked in cabinet in the kitchen. Disinfectants and other toxic materials will be locked in the laundry room. Extra bedding and towels are kept unlocked, in the hallway closet. Knives and sharps will be kept in a locked drawer in the kitchen. Site location has a live in staff bedroom and bathroom that is kept locked, and meets prelicensing requirements. The following requirements need to be addressed and pictures sent to LPA, prior to licensing: - extra mattresses in the garage will be moved out of the home - window sills in the bedrooms will be cleaned - glass window in the backyard will be moved and/or locked in garage - wood with nails in the backyard will be moved and/or locked in garage - extra fence paneling in backyard will be moved to an even surface or secured (not on a hill) - Children's Personal Rights to be posted in a common area - Complaint grievance forms will be posted in a common area This property is ready for licensure, once the above items are corrected and the Licensing Program Manager (LPM) has approved. LPA Pavia will notify licensee of licensure date. Component II: LPA Pavia discussed the following, with Administrator: - Administrator on site hours - facility core services and support - facility emergency intervention plan


summary: Facility Evaluation

raw_content:
Narrative:
On 12/12/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a required annual inspection. LPA met with Licensee Marisa Bonifacio and informed of the purpose of the visit. The facility is still in the process of acquiring a vendor agreement with the local Regional Center. As such, the facility is not yet in operation and has not served any clients. LPA verified that annual fees have been paid. Licensee agrees to notify LPA once the Regional Center vendor certificate is acquired and once the first client is admitted. Using the CARE Inspection Tool, no deficiencies were found. LPA toured the facility site and observed no violations. The facility is well maintained, and outdoor activity space is maintained in safe condition. The facility is readied for client use with four single-occupancy bedrooms, designated storage spaces, and clean linens. An exit interview was conducted, and a copy of this report was left with Licensee Marisa Bonifacio, whose signature on this form confirms receipt.

met_with: Licensee Marisa Bonifacio


summary: Facility Evaluation

raw_content:
Narrative:
On 12/17/24 at 11:30am, Licensing Program Analyst (LPA) Kristin Pierotti conducted an unannounced Annual Inspection at listed facility. LPA met with Alfredo Bonafacio, Licensee/Administrator and toured the facility inside and out. The Group Home is licensed to serve 4 clients. Present during the inspection were 1 staff and 0 clients. At 11:35am, LPA Pierotti toured the facility. LPA Pierotti observed 4 bedrooms and 2 bathrooms. LPA observed facility license, personal rights, facility sketch, meal menu, and other forms posted on the walls throughout the facility. The thermostat read 68 degrees which is within range. Sharps were locked and chemicals were safely stored. There were two days of perishable foods and seven days non-perishable foods present. The medication was also stored and locked in a cabinet in the kitchen. The facility is in good repair and clean. At 11:45am LPA Pierotti toured the backyard. There were no open bodies of water. The backyard was in good repair and clean. At 11:50am LPA Pierotti reviewed 1 client file and 4 staff files. All files were complete and contained all necessary documents. LPA Pierotti interviewed 1 staff and 0 clients. Client was at school during the time of inspection. The CARE Tools was used to conduct this inspection and at this time there are no deficiencies. An exit interview was conducted and a copy of this report was given to Alfredo Bonafacio, Licensee/Administrator whose signature confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/19/2025 at 12: PM, Licensing Program Analysts (LPAs) Mona Lam and Amee Li conducted an unannounced Annual Inspection at the above listed facility. LPAs met with Natasha Lovell, Administrator and inspected the facility inside and out. The Group Home is licensed to serve four clients. Present during the inspection were four staff and four clients. LPAs toured the facility and partially reviewed five staff files. LPAs inspected four bedrooms and two bathrooms. LPAs observed facility license, personal rights, facility sketch, and meal menu posted on the walls throughout the facility. The facility uses dual fire alarm and carbon monoxide detectors located on the ceilings. The thermostat read 70 degrees Fahrenheit. Sharps were locked and chemicals were safely stored. There were two days of perishable foods and seven days non-perishable foods present. The medication was also stored and locked in a cabinet in the kitchen. The facility interior and exterior is in good repair and clean. The facility has no open bodies of water. LPAs inspected the kitchen. The freezer temperature measured at four (4) degrees F. LPAs issued a Technical Violation under California Code of Regulations (CCR) 84076(c)(2). LPAs inspected two client bathrooms. The water temperature initially measured at 133.4 degrees Fahrenheit. LPAs requested that the water temperature be lowered and facility immediately addressed the issue. The water temperature read at 119.3 degrees F on the second measurement. LPAs found that bathroom rugs were not nonslip and issued a Technical Violation under CCR 80087(b)(1). No deficiencies were cited at this time. An exit interview was conducted and a copy of this report was given to Natasha Lovell, Administrator whose signature confirms receipt.

met_with: Natasha Lovell, Administrator


facility_name: HILLSIDE HORIZON

raw_content:
Narrative:
Based on interviews and record reviews the allegation that staff distributed a medication to a client (name unknown) from another client (name unknown) who was placed at another facility, may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Victor Hamaker.

Investigation Findings:
13On December 27, 2023, at 11:20 am, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced inspection to the facility to deliver the findings of the above allegation. LPA met with Victor Hamaker. LPA Erika Lopez conducted an inspection of the facility on February 3, 2023, at 4:30 pm and no immediate deficiencies were observed. Two of four clients (C1, C2, C3, C4), four staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that staff (S1) distributed medication to a client (name unknown) from another client (name unknown) who was placed at another facility. Confidential staff interviews reported that S1 was in charge of distributing the medications during the time of this alleged incident but does not recall administering a client's medication to another client. Confidential interviews reported that it is unclear which medication and or which client(s) this is regarding. LPA made several attempts to interview all of the clients but due to the clients no longer being placed at the facility, LPA was unsuccessful. Other confidential interviews reported that the allegation was true. The interviews that were provided to the LPA were not consistent regarding the allegation. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: HILLSIDE HORIZONFACILITY NUMBER: VISIT DATE: 12/27/2023

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

met_with: Victor Hamaker