facility_name: VE & DAUGHTERS HAPPY HOME #2

raw_content:
Narrative:
Confidential interviews revealed that clients had accessibility to drugs inside the facility by hiding the drugs in private areas on their body. Other confidential interviews indicated that staff check clients' bags, conduct random room checks, and check the perimeter of the facility by looking around the trees and bushes for illegal drugs. Other confidential interviews did not reveal how the drugs were brought into the facility. Based on confidential interviews and information gathered during the investigation, the allegations that S1 had alcohol in the vehicle, S1 drinking alcohol in the presence of clients and lack of supervision resulting C2, C3, C4, C5 using drugs while in care, may have occurred, however, are not supported or proven by evidence. Therefore, the allegations are unsubstantiated. An exit interview was conducted, appeal rights discussed, and a copy of this report was provided to Facility Administrator Rushel Brooks.

Investigation Findings:
13On May 20, 2021 at 2:32PM, Licensing Program Analyst (LPA) Carol Anderson conducted an unannounced tele-inspection via FaceTime due to COVID-19, with Facility Administrator Rushel Brooks to issue the findings of the complaint investigation regarding the above allegations. During the investigation, LPA interviewed six of six clients (C1, through C6), five of eight (S1, through S5) and six County Social Workers. LPA attempted to interview three additional staff members and one witness, but LPA did not receive return calls. LPA reviewed clients Appraisal Needs and Services Plans as well as Special Incident Reports. On January 20, 2021, the Department received a complaint alleging that alcohol was accessible to C1, S1 was drinking alcohol in the presence of C1, and lack of supervision resulting in C2, C3, C4, C5 using drugs while in care. Confidential interviews revealed conflicting statements, S1 had a bottle of alcohol in the front seat of the vehicle while transporting C1, and there was no bottle of alcohol in the vehicle. Confidential interviews revealed that S1 was not under the influence of alcohol in front of C1, and S1 was acting as if S1 was intoxicated. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Carol Anderson 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 08-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, METROPOLITAN DR. # FACILITY NAME: VE & DAUGHTERS HAPPY HOME #2FACILITY NUMBER: VISIT DATE: 05/20/2021

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

met_with: Rushel Brooks via tele-inspection


state: CA

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Investigation Findings:
13On September 3, 2021 at 9:35AM, Licensing Program Analyst (LPA) Carol Anderson met with Fac. Admin. Rushel Brooks. LPA conducted a tele-inspection of the facility on January 25, 2021 at 11:46 am and no immediate deficiencies were observed. Five of five clients (C1, C2, C3, C4, C5), five staff (S1, S2, S3) and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that S1 made an inappropriate comment to C1. Confidential interviews reported that S1 was in the living and C1 overheard S1 make a racial comment. Confidential staff interviews reported that S1 made a comment regarding race but was referring to someone on social media. Confidential interviews denied any inappropriate comments made towards any of the clients in care. Additional interviews reported that C1 got upset at S1 and began calling S1 derogatory names. There no other witnesses to this alleged incident. The interviews that were provided to the LPA were not consistent and did not provide any specific details regarding all of the alleged allegation listed above. Based on interviews and record reviews the allegation that S1 made an inappropriate comment to C1, 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 Fac. Admin. Rushel Brooks. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Carol Anderson 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:

report_type: Complaint Investigation

met_with: Rushel Brooks@ CCL Office

complaint_status: unsubstantiated


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Confidential staff interviews reported that S1 did not make any inappropriate comments to any clients nor did S1 speak to the clients inappropriately. Confidential staff interviews reported that C1 was never denied any approved visitation and while C1 was placed at the facility C1 had family approved overnight visitations. Confidential staff interviews reported that all of the staff treated all the clients the same and some clients had more privileges due to their behaviors and following the facility program. Confidential interviews reported that all of the clients were attending school virtually and had all the necessary equipment that was issued by the school personnel. The facility has two refrigerators and two freezers which had plenty of food that the clients accessed at any time. LPA was unable to interview C1 due to C1 refusing to speak to LPA. There no other witnesses to these alleged incidents. The interviews that were provided to the LPA were not consistent and did not provide any specific details regarding all of the alleged allegations listed above. Based on interviews and record reviews the allegations that S1 speaks inappropriately to the clients, staff did not allow C1 to have approved visitation, staff treats the clients differently than other clients, staff did not assist C1 with obtaining necessary equipment for school and the facility does not have adequate amounts of food, may have occurred, however is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Fac. Admin. Rushel Brooks

Investigation Findings:
13On September 7, 2021 at 9:39AM, Licensing Program Analyst (LPA) Carol Anderson met with Fac,Admin. Rushel Brooks. LPA conducted a tele-inspection of the facility on February 10, 2021 at 03:01 pm and no immediate deficiencies were observed. Three of four clients (C1, C2, C3, C4), five staff (S1, S2, S3,S4,S5) and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that S1 speaks inappropriately to the clients, staff did not allow C1 to have approved visitation, staff treats the clients differently than other clients, staff did not assist C1 with obtaining necessary equipment for school and the facility does not have adequate amounts of food. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Carol Anderson 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 08-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, METROPOLITAN DR. # FACILITY NAME: VE & DAUGHTERS HAPPY HOME #2FACILITY NUMBER: VISIT DATE: 09/07/2021

met_with: Rushel Brooks


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
On March 19, 2021, Community Care Licensing received information which stated staff are verbally abusive to minors while in care while making a racial comment. It was reported that Staff Member #1 made an inappropriate comment. It was advised that Staff Member #1 stated, "I'm tired of this black shit." It was reported that while watching television with another staff and client present, Staff Member #1 made the comment. Information from Administrator corroborated the information and stated that Staff Member #1 admitted to the allegation. Administrator stated Staff Member #1 was counselled and retrained regarding cultural sensitivity. Information obtained from staff interviews stated the inappropriate comment was made. Information from confidential interviews stated they were not present when the comment was made. Information obtained from county social worker supervisor stated there was no known concern. Based on interviews, the allegation that Staff Member was verbally abusive to Client is substantiated at this time. The preponderance of evidence standard has been met. Facility is cited for violation of Interim Licensing Standards, Version three section 87072(d)(11) Personal Rights which posed a potential health, safety and/or personal rights risk to clients in care. A copy of this report along with appeal rights was provided to Administrator Rushel Brooks.

Investigation Findings:
13On November 30, 2021 at 9:54AM, Licensing Program Analyst (LPA) Carol Anderson met with Facility Administrator Rushel Brooks at the San Diego District Office. The visit was conducted in order to provide the findings for the investigation pertaining to the listed allegation. On March 25, 2021, LPA Carol Anderson initiated the complaint investigation. During the investigation, LPA Harris conducted interviews with the Administrator, Staff Member, County Social Worker Supervisor, and one client. LPA Harris was unable to interview additional clients due to clients refusing to be interviewed. Additional staff interviews were attempted but staff did not respond to LPA's multiple requests to interview, furthermore; the staff are no longer employed with the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Carol Anderson 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 08-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, METROPOLITAN DR. # FACILITY NAME: VE & DAUGHTERS HAPPY HOME #2FACILITY NUMBER: VISIT DATE: 11/30/2021

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

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
It was reported that there was an physical altercation between two clients. It was stated that there was not enough supervision present which is why the altercation was conducted. Information obtained from Administrator and staff, stated there was three staff present during the altercation which sufficed the required staff ratio. Information obtained from staff member stated that they did feel that when incidents occur, more staff is needed. Information obtained from confidential interviews stated there was no concern regarding supervision. Information obtained from county social worker supervisor stated there was no known concern. It was also reported that minors were injured during the altercation and staff did not intervene. Information obtained from Administrator stated a client reported injuries and was immediately taken to be evaluated by medical personnel. Administrator stated that information was provided to the assigned county social worker and CCL. It was also stated that staff did not intervene. Administrator stated the facility was "hands off" and staff were not trained to physically intervene. Administrator stated that staff were encouraged and expected to verbally intervene. Information obtained from staff corroborated the information and stated after any incident clients were encouraged to be medically evaluated. Staff Member also stated that Client was taken to the hospital; no concerns. Staff Member also stated she did not intervene due not being Pro-Act trained or allowed to. Staff Member stated she did use verbal commands to try and terminate the fight. Information obtained from confidential and county social worker interviews stated they did not have information pertaining to the incident. Due to not being able to interview additional clients, LPA Harris was unable to make a determination regarding the findings. Based on interviews, the allegations that there was a lack of supervision resulting in minors engaging in verbal and physical altercations, minor sustained injuries while in care, and staff did not intervene during altercations, may have occurred, however is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time.

Investigation Findings:
13On November 30, 2021 at 9:56AM, Licensing Program Analyst (LPA) Carol Anderson conducted a visit to the facility and met with Facility Administrator Rushel Brooks at the San Diego District Office. The visit was conducted in order to provide the findings for the investigation pertaining to the listed allegation. On March 30, 2021, LPA Carol Anderson initiated the complaint investigation During the investigation, LPA Harris conducted interviews with the Administrator, Staff Member, County Social Worker Supervisor, and one client. LPA Harris was unable to interview additional clients due to clients refusing to be interviewed. Additional staff interviews were attempted but staff did not respond to LPA's multiple requests to interview, furthermore; the staff are no longer employed with the facility. On March 23, 2021, Community Care Licensing received information which stated there was a lack of supervision resulting in minors engaging in verbal and physical altercations, minor sustained injuries while in care, and staff did not intervene during altercations. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Carol Anderson 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 08-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, METROPOLITAN DR. # FACILITY NAME: VE & DAUGHTERS HAPPY HOME #2FACILITY NUMBER: VISIT DATE: 11/30/2021

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


raw_content:
Narrative:
It was reported Client #1 was sexually assaulted by other clients and Administrator spoke inappropriately to Client . Administrator stated there were no issues observed or reported that Client #1 was sexually assaulted and physically abused by staff or other clients. Administrator stated Client #1 was not "panted" by other clients either. Administrator stated there were no incident reports regarding Client #1 due to no information being provided. Information obtained from staff stated they were not aware of any issues regarding Client #1. Staff stated Client #1 would communicate if there were any concerns. Staff also stated she did not believe there were any concerns of bullying Client #1 either. Information obtained from confidential interview stated they did not observe any issues regarding sexual or physical abuse towards Client #1. Information obtained from county social worker interviews stated they did not have information pertaining to the incident. Due to not being able to interview additional clients, LPA Harris was unable to make a determination regarding the findings. Based on interviews, the allegations that staff did not intervene during altercations, Client sustained injuries while in care, and Client's property was destroyed may have occurred, however is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time.

Investigation Findings:
13On November 30, 2021 at 10:02AM, Licensing Program Analyst (LPA) Carol Anderson met with Facility Administrator Rushel Brooks at the San Diego District Office. The visit was conducted in order to provide the findings for the investigation pertaining to the listed allegations. On March 30, 2021, LPA Carol Anderson initiated the complaint investigation and interviewed Administrator. During the investigation, LPA Harris conducted a subsequent interview with Administrator, Staff Member, County Social Worker Supervisor, and one client. LPA Harris was unable to interview additional clients due to clients refusing to be interviewed. Additional staff interviews were attempted but staff did not respond to LPA's multiple requests to interview, furthermore; the staff are no longer employed with the facility. On March 24, 2021, Community Care Licensing received information which minor is being abused and staff speak inappropriately towards minor. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Carol Anderson 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 08-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, METROPOLITAN DR. # FACILITY NAME: VE & DAUGHTERS HAPPY HOME #2FACILITY NUMBER: VISIT DATE: 11/30/2021

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


raw_content:
Narrative:
On April 7, 2021, Community Care Licensing (CCL) received information which stated that staff did not intervene during altercations, minor caused injuries to another minor in care, and minor caused damage to minor's belongings. It was reported that there was a physical altercation between Client #1 and Client #2. It was reported that the altercation began because Client #1 poured liquid on Client #2's belongings. It was advised that the liquid was not poured on any of Client #2's belongings. Information obtained could not corroborate the information provided. It was reported that minors were injured during the altercation and staff did not intervene. Information obtained from Administrator stated a client reported injuries and was immediately taken to be evaluated by medical personnel. Administrator stated that information was provided to the assigned county social worker and CCL. It was also stated that staff did not intervene. Administrator stated the facility was "hands off" and staff were not trained to physically intervene. Administrator stated that staff were encouraged and expected to verbally intervene. Information obtained from staff corroborated the information and stated after any incident clients were encouraged to be medically evaluated. Staff Member also stated that that Client was taken to the hospital; no concerns. Staff Member also stated she did not intervene due not being Pro-Act trained or allowed to. Staff Member stated she did use verbal commands to try and terminate the fight. Information obtained from confidential and county social worker interviews stated they did not have information pertaining to the incident. Due to not being able to interview additional clients, LPA Harris was unable to make a determination regarding the findings. Based on interviews, the allegations that staff did not intervene during altercations, Client sustained injuries while in care, and Client's property was destroyed may have occurred, however is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time.

Investigation Findings:
13On November 30, 2021 at 10:07AM, Licensing Program Analyst (LPA) Carol Anderson met with Facility Administrator Rushel Brooks at the San Diego District Office. The visit was conducted in order to provide the findings for the investigation pertaining to the listed allegations. On April 15, 2021, LPA Carol Anderson initiated the complaint investigation During the investigation, LPA Harris conducted interviews with Administrator, Staff Member, County Social Worker Supervisor, and one client. LPA Harris was unable to interview additional clients due to clients refusing to be interviewed. Additional staff interviews were attempted but staff did not respond to LPA's multiple requests to interview, furthermore; the staff are no longer employed with the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Carol Anderson 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 08-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, METROPOLITAN DR. # FACILITY NAME: VE & DAUGHTERS HAPPY HOME #2FACILITY NUMBER: VISIT DATE: 11/30/2021

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


raw_content:
Narrative:
On April 27, 2021, Community Care Licensing (CCL) received information which stated staff did not prevent clients from smoking marijuana. It was reported that clients were able to smoke marijuana in the home. Information obtained from Administrator stated that clients did begin to smoke in the home without permission. Administrator stated staff would encourage clients to follow the program and listen to staff directives. Administrator stated when staff would observe clients smoking, staff would ask clients to stop and attempt to retrieve the contraband. Administrator stated authorized representatives and CCL were notified. Administrator denied that law enforcement was contacted. Administrator stated the facility did have drug abuse counseling for clients as well. Information obtained from staff corroborated the information provided by Administrator. Staff stated they would try their best to encourage clients to follow the rules. Information obtained from confidential interview stated that clients did smoke in the home, but staff did not allow clients; clients did not care about following rules. Information obtained from confidential and county social worker interviews stated they did not have information pertaining to the allegation. Due to not being able to interview additional clients, LPA Harris was unable to make a determination regarding the finding. Based on interviews, the allegations that staff did not intervene during altercations, Client sustained injuries while in care, and Client's property was destroyed may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time.

Investigation Findings:
13On November 30, 2021 at 10:11AM, Licensing Program Analyst (LPA) Carol Anderson met with Facility Administrator Rushel Brooks at the San Diego District Office. The visit was conducted in order to provide the findings for the investigation pertaining to the listed allegation. On May 6, 2021, LPA Carol Anderson initiated the complaint investigation. During the investigation, LPA Harris conducted interviews with Administrator, Staff Member, County Social Worker Supervisor, and one client. LPA Harris was unable to interview additional clients due to clients refusing to be interviewed. Additional staff interviews were attempted but staff did not respond to LPA's multiple requests to interview, furthermore; the staff are no longer employed with the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Carol Anderson 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 08-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, METROPOLITAN DR. # FACILITY NAME: VE & DAUGHTERS HAPPY HOME #2FACILITY NUMBER: VISIT DATE: 11/30/2021

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


raw_content:
Narrative:
Confidential interviews reported that the residents of the facility often had on and off again sexual relationships with one another. Confidential interviews reported when staff would observe inappropriate sexual behavior occurring between residents' staff would attempt to separate the residents by giving verbal directions. Confidential interviews also reported if staff caught the residents having sexual interactions, staff would not follow up on the incidents. Confidential interviews could not confirm, or dispute staff attempted to separate C1 and C3 during this incident nor were confidential interviews able to confirm or dispute C1 was a consenting participate during the incident. Based on confidential interviews the allegation lack of supervision resulted in minor (Child #1 [C1]) being sexually abused by another minor (Child #3 [C3]) while in care, however it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of the report was provided along with appeal rights to with VE & Daughters Facility Administrator Rushel Brooks.

Investigation Findings:
13On February 28,2022 at 5:30PM, Licensing Program Analyst (LPA), Carol Anderson, met with VE & Daughters Facility Administrator Rushel Brooks, to deliver the finding for the above stated allegation. A health and safety inspection did not occur when the complaint was opened with the facility on 7/14/2021 due to the licensee's-initiated closure of the facility occurring on June 24, 2021. The investigation was conducted by Special Investigator Ernestina Bellucco and LPA Strickland and included interviews with Administrator (ADM), Staff #1 (S1), three former foster youth placed at the facility (Child #1 (C1), Child #2 (C2), Child #3 (C3). County Social Worker #1 (CSW1), County Social Worker #2 (CSW2). In addition, county records and facility records were reviewed. On July 8, 2021, Community Care Licensing (CCL) received an allegation alleging lack of supervision resulted in minor (Child #1 [C1]) being sexually abused by another minor (Child #3 [C3]) while in care. Specifically, it was reported on an unknown date C1 was under the influence when C1 was sexually abused by C3. Confidential interviews reported that the residents of the facility often had on and off again sexual relationships with one another. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Carol Anderson 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 08-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, METROPOLITAN DR. # FACILITY NAME: VE & DAUGHTERS HAPPY HOME #2FACILITY NUMBER: VISIT DATE: 02/28/2022

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


summary: Facility Evaluation

raw_content:
Narrative:
On May 25, 2021 at 9:00AM, Licensing Program Analyst (LPA) Carol Anderson conducted a tele-inspection via Face Time due to COVID-19, with Facility Administrator Rushel Brooks to deliver a report regarding an office conference that was held on May 24, 2021, with VE and Daughters Happy Home Short Term Residential Therapeutic Program (STRTP), via MS Teams due to the COVID-19 pandemic. In attendance were: Community Care Licensing (CCL) representatives, Regional Manager (RM) Lacresha Cook, Licensing Program Managers (LPM) Stephanie Hudak and Ann Valenzuela, Licensing Program Analysts (LPA) Carol Anderson and Babatunde Aborchie; STRTP representatives, Vilma Davis, CEO/Founder, Tatiana Sankar, CFO/Co-Founder, Roisin Doy, Head of Service and Rushel Brooks, Administrator; and Riverside County Placement Representatives, Nisha Elliott, Behavioral Health, and Karin Atkis, Supervisor of Out-of Home Investigations. The following issues were discussed: Complaints Personnel Requirements Admission Policies Extension for the provisional STRTP license (12 mos. expires 7/21/21) During the meeting, LPM Hudak discussed the increase of complaints that occurred in the last three years. In 2021 there were ten complaints, 2020 there were 12 complaints and 2019 there were eight complaints. LPM Hudak discussed the patterns of the complaints relating to care and supervision. Per administrator, stated that increase of issues at the facility were in relation to clients in the home wanting to be out in the community but couldn't due to COVID pandemic. LPM Hudak discussed what kind of indoor activities are being provided to the clients. STRTP representatives stated that due to COVID-19, the indoor activities consist of Arts/Crafts, games, gardening, and various puzzles. STRTP representatives stated for outdoor activities they were doing beach walks and community walks. STRTP representatives stated prior to COVID-19 clients were taken to YMCA on a regularly basis for swimming. STRTP representatives stated activities are being offered but clients do refuse to participate in the activities or client's AWOL from the facility. LPM Hudak discussed the personnel requirements as it relates to staffing and crisis situations. STRTP representatives stated staff meetings are held every Monday. Staff goes over intervention techniques as incidents occur in the facility. LPM Hudak asked who the current Pro-Act trainer was and if current staff are trained, per the emergency intervention plan in their program statement. CFO stated she needs to attend the Pro-Act trainer re-certification course to do the training for staff. Ms. Doy stated she has been working with staff on different crisis intervention techniques and de-escalation communication with staff as she is present in the facility Monday through Friday 12-8:30pm. It was also discussed by CCL staff on what mental health services are being provided by the facility. STRTP representatives stated that most of the 1:1 therapy and drug and alcohol treatment is being provided by outside sources that include Vista Hill and McAllister. Ms. Doy stated she is a master's level social worker, not licensed, and not currently being supervised by a licensed therapist. It was also discussed by Riverside County representative, Ms. Elliott, that crisis intervention plan and training has to be completed by licensed mental health worker. Again, the facility stated they currently do not have a licensed mental health professional providing those services and currently looking for someone to fill that role. Both LPM Hudak and RM Cook emphasized to the STRTP representatives that they must follow their approved plan of operation and program statement, especially regarding the emergency interventions they are utilizing within the program as this is a basis to some of the current complaint issues. At this time, CCL is requesting a Corrective Action Plan due by 6/24/21, to include the following: 1) What the plan is for the operation of the facility if the STRTP license expires. 2) What the plan will be for crisis intervention training and implementation in the facility until a licensed mental health professional is hired. 3) What is the plan for in-house mental health services until a licensed mental health professional is hired. In closing, all parties were satisfied with all information that was discussed during the meeting. A copy of this report was given to and reviewed with Facility Administrator Rushel Brooks LPM Hudak also discussed admission policies and what the current plan is with accepting new placements. Ms. Brooks and Ms. Doy state, they are looking at compatibility when accepting new placements from the various counties. Current placements include clients from Riverside, Kern, and San Bernardino Counties. Riverside County representative, Ms. Atkins gave input on all the Child Protective Services Referrals that are receiving as well for their placements and they have seen an increase in lack of staff interventions. Lastly, the status of the STRTP provisional license was discussed. STRTP stated they started the process in 2018 for accreditation with Joint Commission, then stopped to work on STRTP application, and most recently started the process again. Currently, San Diego County Behavioral Health and Human Services is not contracting with them which has caused the facility to withdraw their Mental Health Application with the State of California. LPM Hudak provided information that per the current STRTP guidelines, in order for CCL to justify the extension of the provisional license past the 12-month expiration date, the facility needs to be in the process of obtaining Mental Health Approval and/or Accreditation. STRTP representatives were looking forward to applying for a contract again with San Diego County next year. Information that CCL received from San Diego County, was that new Mental Health contracts with San Diego County would not occur to 2023, which would be well pass the 18-24-month mark of the provisional license. LPM Hudak explained to facility representatives that they would need to make a decision on what their plan is for their facility since they did not have any confirmation of a mental health contract from a county to move forward with the provisional license extension. Suggestions of Transitional Housing facility or converting back to a Group Home for private pay or Regional Center was given.

report_type: Facility Evaluation

met_with: STRTP Representatives , Rushel Brooks


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
On September 7, 2021 at 9:30AM, Licensing Program Analyst (LPA) Carol Anderson met with Rushel Brooks, Facility Administrator for VE and Daughters Happy Home #2 in the San Diego Community Care Licensing (CCL) to deliver findings regarding an informal conference held on May 24, 2021 at 9:00AM, with VE and Daughters Happy Home # Short Term Residential Therapeutic Program (STRTP) facility representatives, via MS Teams due to COVID-19. During the informal conference the plan of operation was discuss and determine the facility was out of compliance with their plan of operation. The facility plan of operation is in violations of the Interim Licensing Standards STRTP (ILS) (Version 3.1). Based on interviews and information during the informal conference on 5/24/21, the preponderance of evidence standard has been met and the Department has determined that the facility plan of operation is substantiated. This pose an immediate Health and Safety risk to client in care. The facility cited for California Code of Regulations, Title 22, Division Interim Licensing Standards (STRTP)(ILS) (Version 3.1.) An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Rushel Brooks, Facility Administrator.

Deficiencies:
87001: 8
9
10
11
12
13
14
87095.66(b): 1
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4
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7

visit_type: Case Management

met_with: Rushel Brooks @ CCL Office

title:
(m) (4)  Mental health head of service" means the licensed mental health professional or mental health rehabilitation specialist, as defined in Section 630 of Title 9, who has been designated by a short-term residential therapeutic  program licensee to oversee and implement the overall mental health treatment program in accordance with the provisions of the short-term rehabilitation therapeutic program mental health program protocol.
The requirement is not met as evidence by

description:
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title:
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787095.66 (b) Staffing Requirements
	All staff who will use emergency interventions must be trained in the appropriate emergency intervention techniques approved to be used by the licensee.
The requirement is not met as evidence by

description:
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facility_name: VERA'S SANCUARY I

raw_content:
Narrative:
in care. Specifically, it was reported on March 29, 2021, S1 was in C1's room before bedtime when the S1 held C1's hands over C1's head and began kissing C1. Confidential interviews and record review could not confirm or dispute an incident had occurred. Confidential interviews deny witnessing any inappropriate interactions between S1 and C1. Confidential interviews could only provide that there was a weird vibe between C1 and S1. Confidential interviews further reported S1 had reported concerns with boundaries regarding C1. Confidential interviews were unable to provide what the boundary concerns were and what if anything was done regarding the concerns. Record review could neither confirm nor dismiss S1's concerns regarding boundary issues with C1 were reported or addressed. Based on record review and confidential interviews, the allegation of Staff (Staff #1 (S1) sexually abused a minor (Child #1 (C1), may or may not have occurred, however it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. Licensing Program Analyst (LPA) received email authority from Anasheh Sarfarian to allow Morgan Salmans, Facility Manager to sign on behalf of the facility. A copy of this report and appeal rights was discussed and provided to Morgan Salmans.

Investigation Findings:
13On July 6, 2021, Licensing Program Analyst (LPA) Nicole Strickland met with faciity manager Morgan Salmans to deliver Amended findings of a report that was initally delivered on July 2, 2021, at 11:30am. Licensing Program Analyst (LPA) Nicole Strickland met with Vera's Sancuary Head of Service Michellle Menke to deliver the finding of the complaint investigation for the above allegation involving client (C1) as identified on the Confidential Names List (LIC 811). The investigation was conducted by Special Investigator Annette Renquist with Community Care Licensing's (CCL) Investigations Branch Bureau. The investigation included interviews with eight staff (Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), Staff #4 (S4), Staff #5 (S5), Staff #6 (S6), Staff #7 (S7), and Staff #8 (S8), and Child #1 (C1), In addition, county records and facility records were reviewed. On April 1, 2021, CCL received an allegation Staff (Staff #1 (S1) sexually abused a minor (Child #1 (C1) while UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Nicole Strickland LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: VERA'S SANCUARY IFACILITY NUMBER: VISIT DATE: 07/02/2021

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

met_with: Morgan Salmans


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

raw_content:
Narrative:
During the course of the investigation, the LPA conducted confidential interviews with seven staff. The LPA attempted to interview the three involved clients but they were not present when the LPA completed inspections to the facility, had been discharged from the facility or were on run away status. The LPA also completed a review of facility documentation. Allegation #1) It was alleged from April 2021-July 1, 2021, hot food was left out from 1: PM-9: PM. The LPA received corroborating information from staff that dinner would be prepared and placed on the kitchen counter or on top of the dryer by 3:30 p.m. There was no set time for dinner. The clients would serve themselves and eat when they wanted to. The food would not be refrigerated and left out overnight. When the staff arrived the next morning, they would dispose of the food. It was reported to the LPA this occurred multiple times. Allegation #2) It was alleged that staff #1 (S1) and staff #2 (S2) told client #1 (C1) to shut up and called C1, "Ghetto." S1 reported to the LPA, the incident occurred around 06/20/21. C1 was very aggressive, called S1 names and got in S1's face. S1 told C1 the way C1 was speaking to S1 was ghetto and C1 needed to stop calling S1 the, "Work Nigger," and "Work Nigga." C1 also called S1 a, "Fucking bitch," and "Bruh." S2 denied making the alleged statements and further denied being present during the incident. During confidential interviews, it was reported to the LPA S1 was constantly inappropriate with the clients. A client would yell at S1 and S1 would yell back, tell them to shut up and get in the client's face. It was further reported S1 admitted to the incident. S1 was frustrated about not receiving support from the administrator at the time. S1 apologized to the client. The LPA did not receive any evidence that S2 made the alleged comments. Allegation #3) It was alleged from April 2021-July 1, 2021, Anasheh Safarian (S3) was listed as the administrator of record. During this time, the facility had two administrators. S3 was the administrator during the day and Charmaine Linley (S9) was the administrator at night. S3 was present at the facility only four times from April 2021-July 1, 2021. S3 worked out the licensee's corporate office in Sun Valley, CA. During confidential interviews, the LPA received corroborating information that S3 was not on the facility premises each week. It was reported S3 was the administrator on paper only. S3's work was performed at the licensee's corporate office. The facility submitted a letter and supportive documents to CCL, dated 04/08/21, indicating S3 was the administrator effective 04/08/21. The facility did not report to CCL that S9 was hired or that S9 would be an administrator in addition to S3. *** *** Allegation #4) It was alleged that staff did not receive required training. There were multiple staff who supervised the clients in the facility swimming pool in May and June of 2021, but did not have water safety certificates. The facility was licensed on 09/15/20 but the licensee did not offer the water safety training prior to April of 2021. The LPA requested proof of completed water safety training from the facility for the staff who supervised the clients in the facility swimming pool in May and June of 2021. The facility submitted copies of the certificate of completion for the American Red Cross Water Safety for Parents and Caregivers for some of the staff but no proof was provided for S1 and staff #6 (S6). In addition, the certificate of completion for S2 was dated 07/15/21, after S2 had provided the supervision. Allegation #5) It was alleged from April 2021-July 1, 2021, the facility bathrooms and bedrooms were only cleaned on Monday (by a professional cleaning crew) and that on other days bathroom trash would be left overflowing and there were dirty counters and floors. On 6/10/2021, a client dyed their hair black and walked through the facility, staining floors in the hallway and bathroom. During confidential interviews, the LPA received corroborating information when the morning staff reported to work, the facility was dirty on a weekly basis. The trash was not taken out, the kitchen, living room and the clients' rooms were dirty. The LPA completed a safety inspection of the facility on 07/14/21 at 11: AM. Although the facility was clean, the LPA observed black dye on the door jam in the client bathroom. Based on confidential interviews, document review and the LPA's observation, the preponderance of evidence standard has been met and the allegations food was not stored in a safe manner, S1 spoke inappropriately to C1, facility administrator was not on the premises 20 hours a week, facility staff were not properly trained and the facility was not kept clean are substantiated. Facility is cited for violation of Title 22, Division 6, Chapter 1 80076(a)(14) Food Services, 80065(e)(2) Personnel Requirements, 80087(a) Buildings and Grounds and the Interim Licensing Standards Article 6 87072(c)(10) Personal Rights and 87064(b)(1) Administrator Qualifications and Duties on the next pages. A copy of this report, the LIC Confidential Names, and appeal rights were provided to Mariam Mott. Allegation #1) It was alleged from April 2021-July 1, 2021, the facility did not have enough milk or two days worth of perishable items. The staff would also feed the clients fast food. During the course of confidential interviews, it was reported to the LPA there was always a supply of fresh food. The food was purchased from Shamrock Foods Company (commercial food supplier) and delivered every Thursday. If the clients did not like what was on the menu, they were allowed to request other food items. The staff would then go purchase the requested food items. Four gallons of milk a were ordered each week. If the milk supply ran low, they would order through Instacart (grocery delivery service). The LPA completed a safety inspection of the facility on 07/14/21 at 11: AM and observed the food supply. There was an adequate supply of food and perishables. The LPA also obtained copies of invoices from Shamrock Foods Company from 05/01/21-7/8/21. The facility consistently ordered food each week, including milk and perishables. However, other information was received that the pantry was empty seven or eight times. One time was due to the house being bombed for bugs. Allegation #2) It was alleged from April 2021-July 1, 2021, that dated menu documentation was not available. The menus were posted a couple of times and they were outdated. During the course of confidential interviews, it was reported to the LPA the weekly menus were posted on the refrigerator. The menu copies were kept for months in the staff office. In addition, there were electronic copies of the menus. The LPA completed a safety inspection of the facility on 07/14/21 at 11: AM and observed four weeks of dated menus posted on the side of the refrigerator and the menu for the day on a decorative chalkboard on the kitchen counter. However, other information was received that the menus were not posted prior to 07/13/21. Allegation #3) It was alleged from April 2021-July 1, 2021, adults from the licensee's substance use disorder (SUD) site across the street from the facility were allowed to come into the facility with the clients and were left alone with clients and act as mentors to the clients. It was a regular practice to have staff working in the facility that did not have a criminal record clearance. It was alleged staff #10 (S10) did not have a criminal record clearance on 6/10/2021. S10 was allowed to supervise the clients prior to being fingerprint cleared. During the course of confidential interviews, it was reported to the LPA the clients were never left unsupervised with the adults from the SUD site. Vera's Sanctuary (VS) staff were always present. *** *** The adult clients and VS clients had group sessions together on the VS porch for approximately two months and the adult clients would come to the VS swimming pool to hang out. The group sessions and the adult clients visits to the swimming pool were stopped by the facility after LPA Torres completed the 10 day inspection for this complaint on 07/14/21. The LPA verified through the CCL database that S10 had a criminal record clearance and was associated to the facility on 05/10/21. However, other information was received stated the clients would go across the street to the SUD facility to play pool (billiards) in the garage. The adult clients were also present in the garage and no VS staff were supervising the clients. This happened five times. It was a regular practice to have staff working in the facility that had not received a criminal record clearance. Based on confidential interviews, the allegations the facility did not have enough milk or two days worth of perishable items, menus were posted a couple of times and they were outdated, adults from the SUD site were allowed to come into the facility with the clients and were left alone with clients and it was a regular practice to have staff working in the facility that did not have a criminal record clearance may have occurred, however, are not supported or proven by evidence. Therefore, the above allegations are unsubstantiated at this time. An exit interview was conducted and a copy of this report, the LIC Confidential Names and appeal rights were provided to Mariam Mott.

Investigation Findings:
13On 08/03/22 at 11: AM Licensing Program Analyst (LPA) Belinda Torres conducted a subsequent complaint inspection for the purpose of delivering the investigative finding to the allegations listed above. The LPA met with Mariam Mott, Clinical Director. The LPA received verbal authorization from Anasheh Safarian for Mariam to sign for this report. On 07/02/21, Community Care Licensing (CCL) received a complaint alleging facility staff would cook food and leave it out on the counter for the entire day and evening, staff told a client to shut up and called the client ghetto, the facility Administrator, Anasheh Safarain, is not at the facility 20 hours a week, staff members do not receive the "required outside training hours" and multiple staff who supervised the clients in the swimming pool did not have water safety certificates and the bathroom trash was overflowing and there were dirty counters and floors. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Belinda Torres LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: VERA'S SANCTUARY IFACILITY NUMBER: VISIT DATE: 08/03/2022

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

Deficiencies:
80087(a): 1
2
3
4
5
6
7

met_with: Mariam Mott

title:
Buildings and Grounds. The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement was not met as evidenced by

description:
1
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raw_content:
Narrative:
Allegation #1) It was alleged there were no planned activities and in April and May of 2021 there was no outing/activity money available at the facility. Administration advised that they had forgotten to give the money to the facility. During the course of the investigation confidential interviews were conducted, it was reported to the LPA that S9 did not want to take the clients out because S9 was scared the clients would steal. The staff had the funds and ability to take the clients out but S9 did not want to. It was further reported to the LPA the staff did what they could given the COVID- Pandemic. The clients were provided the following activities: Taco Tuesday at Rosa's Cantina, movies in the park outside on the facility grounds, an ice cream truck would come to the facility each week, pool days with a barbecue, trips to the salon to get their nails done, trips to the hair shop, Knott's Berry Farm and Disneyland. However, other information was received that the clients would watch Tik Tok (social media) and videos all day. The staff and clients would go in the community and the clients would steal from the store. There was always plans for activities but there was never any money available. There were no funds for staff to use or petty cash. Allegation #2) It was alleged on a holiday between April 2021-July 1, 2021, one or two clients went to S4's house for a few hours because staff called off and the facility was short staffed. Reportedly S4 was advised by Orange County Children and Family Services the clients could not hang out with S4's 18 year old foster child. During the course of the investigation confidential interviews were conducted, the LPA did not receive any corroborating information on whether the clients went to S4's house and/or spent time with S4's foster child. It was further reported to the LPA, the clients were always in the staff's care. If the clients did go to S4's home, there would have been a staff present. Allegation #3) It was alleged from April 2021-July 1, 2021, client #2 (C2) was not required to attend therapy. During the course of the investigation confidential interviews were conducted, it was reported to the LPA C2 was supposed to go therapy before or after work but C2 refused to go. When C2 was not working on the weekends, C2 still refused to go to therapy. The staff would try to get C2 to go to therapy but they could not force C2 to participate. However, other information was received that C2 did not have to attend therapy and needed to focus on working. Based on confidential interviews, the allegations there were no planned activities in April and May of 2021, there was no outing/activity money available at the facility, clients spent unauthorized time with S4's foster child and clients who had jobs were not required to participate in therapy may have occurred, however, are not supported or proven by evidence. Therefore, the above allegations are unsubstantiated at this time. An exit interview was conducted and a copy of this report, the LIC Confidential Names and appeal rights were provided to Mariam Mott.

Investigation Findings:
13On 08/03/22 at 12: PM Licensing Program Analyst (LPA) Belinda Torres conducted a subsequent complaint inspection for the purpose of delivering the investigative finding to the allegations listed above. The LPA met with Mariam Mott, Clinical Director. On 07/02/21, Community Care Licensing (CCL) received a complaint alleging there were no planned activities and in April and May of 2021 there was no outing/activity money available at the facility, clients spent unauthorized time with S4's foster child and clients who had jobs were not required to participate in therapy. During the course of the investigation, the LPA conducted confidential interviews with seven staff. The LPA attempted to interview the three involved clients but they were not present when the LPA completed inspections to the facility, had been discharged from the facility or were on run away status. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Belinda Torres LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, THE CITY DR., SUITE FACILITY NAME: VERA'S SANCTUARY IFACILITY NUMBER: VISIT DATE: 08/03/2022

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


raw_content:
Narrative:
(C1) was observed with a hicky and notes C1 participated in sexualized behavior. Confidential interviews could not confirm or dispute this was a consensual interaction, or that this was the incident resulting in the allegation of sexual abuse. Confidential interviews could not confirm or dispute the allegation. An additional allegation was received by CCL, alleging staff purchased drugs for minors while in care. No specific information regarding which staff or which minors were involved in this allegation was provided. Record review and confidential interviews were unable to provide evidence confirming or disputing this allegation. Two additional allegations were received by CCL alleging minors are not allowed to leave the home and staff demonstrate inappropriate forms of punishment. Specifically it was reported staff did not let any of the minors leave the home and staff refused to allow (child #1 [C1]) to leave the facility to purchase hygiene supplies as a form of punishment for not attending class. Record review and confidential interviews reported that none of the residents had community passes approved by their County Social Workers at the time of the allegation. Confidential interviews reported the facility provided hygiene products for the residents and if the residents wanted to purchase special items staff would take them and accompany them to the store. Confidential interviews could not confirm, or dispute minors were not allowed to leave the home and staff refused to allow C1 to leave the facility as a form of punishment. An additional allegation alleging staff do not ensure the minors are properly fed while in care was also received by CCL. Specifically it was reported that food is not satisfactory, and the good food was locked up. Confidential interviews reported that the minors wanted more of the unhealthy fast food type of meals and would complain about what the chef had made for dinner. Confidential interviews could not confirm or dispute the allegation. Based on record review and confidential interviews the minors are sexually abused while in care, staff purchased drugs for minors while in care, minors are not allowed to leave the home, staff demonstrate inappropriate forms of punishment, and staff do not ensure the minors are properly fed while in care, may or may not have occurred, however they are not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of the report was provided along with appeal rights to Andrea "Dre" Carmona.

Investigation Findings:
13On October 13, 2022 at 2:00 pm Licensing Program Analyst (LPA), Nicole Strickland, arrived at the facility to deliver findings for the above allegations. LPA previously spoke with and received emailed permission from Vera's Sanctuary Administrator, Anasheh Safarian to meet with Andrea "Dre" Carmona and for "Dre" to accept and sign reports on behalf of Vera's Sanctuary 1. LPA conducted an inspection of the facility on September 28, 2021 at approximately 11:00 am and no immediate deficiencies were observed. The investigation included interviews with three staff (Staff #1 [S1], Staff #2 [S2], Staff #3 [S3]), four foster youth (Child #1 [C1], Child #2 [C2], Child #3 [C3], and Child #4 [C4]). In addition, county records and facility records were reviewed. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Nicole Strickland LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: VERA'S SANCTUARY IFACILITY NUMBER: VISIT DATE: 10/13/2022

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

met_with: Andrea Carmona


raw_content:
Narrative:
Mena obtained conflicting information during interviews. Confidential interviews denied that any inappropriate sexual behavior had taken place between C1 and Child # 2 (C2). Confidential interviews also denied that staff did not fulfill reporting requirements or that S1 had engaged in an inappropriate relationship with C1. According to confidential interviews, S1's relationship with C1 was more of an older sibling or mother-daughter relationship. Confidential interviews also stated that although C1 had gained access to a knife and alcohol on separate occasions, it was not due to a lack of supervision, but due to C1 smuggling in contraband without staff's knowledge and C1 having taken or stolen key from staff where knives were stored. While other confidential information received by Licensing Office stated that these allegations had occurred. LPA Mena was unable to conduct a follow-up interview with Child # 1 (C1), due to C1's current whereabouts being unknown. There were no other known witnesses to these allegations. Based on confidential information obtained during the course of this investigation, the allegations that Child # 1 had access to alcohol and sharp object, and that facility staff did not fulfil reporting requirements, did not prevent inappropriate sexual behavior between clients while in care, and that Staff # 1 (S1) had engaged in an inappropriate relationship with C1, may have occurred, however is not supported or proven by evidence. Therefore, the above allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided

Investigation Findings:
13Licensing Program Analyst (LPA), Daniel Mena met with Program Director, Andrea Carmona to discuss the investigative findings for the above stated allegations. LPAs Cheraki Davis and Daniel Mena conducted an inspection to the facility on December 13, 2021 at 9:00am and on May 12, 2021 at 11:21am. No immediate hazards observed. Special Investigator (SI), Charlotte Jackson and LPA Mena interviewed five Staff (S1, S2, S3, S4 & S8), two foster children (C1 & C2), County Social Worker (CSW), Probation Officer (PO), Facility Administrator (AD), as well as reviewed police, client and facility records. Community Care Licensing received information on December 07, 2021 alleging that Child # 1 had access to alcohol, as well as a sharp object. Allegation also claimed that facility staff did not fulfil reporting requirements, did not prevent inappropriate sexual behavior between clients while in care, and that Staff # 1 (S1) had engaged in an inappropriate relationship with C1. Information obtained in confidential interviews did not corroborate the allegation with a preponderance of evidence. IB investigator and LPA UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Daniel Mena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: VERA'S SANCTUARY IFACILITY NUMBER: VISIT DATE: 11/04/2022

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


raw_content:
Narrative:
(**Continued from LIC 9099**) Additionally, two staff members (S1, S3) could not be reached for an interview after multiple attempts made by LPA Urena for an interview. Due to an absence without leave (AWOL) status C1 could not be reached for comment regarding the allegations. During investigation, a confidential interview could not provide details about the allegations involving C1, and S1 due to being hired after C1 left the facility and due to little interaction with S1. Confidential interview further stated that some clients did smoke while in care and smoked outside of the facility premises, which was against the program's rules. Confidential interview denied hearing anything about S1 or C1 that pertained to the allegations. Additionally, S1, S3 and C1 could not be reached for comment. There were no other known witnesses to the allegations. LPA received inconsistent information regarding the allegations. Based on confidential interview and record review the allegation that a staff member took C1 to a smoking establishment, C1 smoked in the presence of staff members, staff members gave C1 a smoking device, and S1 inappropriately touched C1, may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights will be emailed to Administrator, Anasheh Safarian. Copies of the original signatures will be placed with the complaint file.

Investigation Findings:
13On May 2, 2023, at 1: PM, Licensing Program Analyst (LPA) Cynthia Urena spoke with Vera's Sanctuary I Short Term Residential Therapeutic Program (STRTP) Administrator, Anasheh Safarian to deliver the investigative finding of the above stated allegations. On April 21, Community Care Licensing received a complaint alleging that a staff member took minor to a smoking establishment, minor smoked in the presence of staff members, staff members gave minor a smoking device, and staff member inappropriately touched minor. Due to the facility's closure on March 9, 2022, no inspection was conducted. However, LPA Torres conducted an interview with a Facility Manager on April 26, 2022, and requested copies to be mailed out from the STRTP'S Programs staff, and client files. LPA Torres made attempts to contact client #1 (C1's) Authorized Representatives but LPA's Torres's messages were not returned. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 22-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY NAME: VERA'S SANCTUARY IFACILITY NUMBER: VISIT DATE: 05/02/2023

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

met_with: Administrator, Anasheh Safarian


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Nicole Strickland arrived to the facility unannounced and met with Facility Manager Morgan Salmans to deliver an amended report that was initially delivered on July 2, 2021.


summary: Facility Evaluation

raw_content:
Narrative:
On 09/13/21 at 10: AM, Licensing Program Analyst (LPA) Belinda Torres met with Morgan Salmans, Facility Manager/Administrator Designee for the purpose of conducting a post licensing inspection of the facility. At 11: AM, Morgan led the physical inspection of the facility with the LPA. A physical plant inspection was completed and included the facility's building and grounds, kitchen area, refrigerator/freezers, food storage areas, client bedrooms, bathroom/showers and facility vehicles used to transport clients. The facility grounds were clean and free of debris and observable hazards. Sports equipment/toys/books/games/computers were observed for children's schooling and recreation time. There is adequate indoor and outdoor activity space. Facility smoke detectors and carbon monoxide detectors are in appropriate working order. Licensee maintains an adequate supply of perishable and non-perishable foods and the menu was posted. All other required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights, Emergency Disaster Plan and Foster Care Ombudsperson poster. Medications are locked and centrally stored inside staff's office. The facility ensures that there is one client per bed with appropriate linens, pillows, comforters, and mattresses in good repair. All bedrooms have individual beds and drawer space for each client. The hot water in the client's bathrooms was measured to be between 103 and 116 degrees. Per Morgan, no firearms or weapons are allowed in the facility. Chemicals and/or poisons are locked in the hallway closet. The LPA reviewed LIC 610C Emergency Disaster Plan, completed disaster training for staff and clients and completed emergency drills. Due to time constraints, the inspection will have to be completed on a subsequent day. A copy of this report was provided to Morgan Salmans.


summary: Facility Evaluation

raw_content:
Narrative:
On 09/16/21 at 11: AM, Licensing Program Analyst (LPA) Belinda Torres met with Lauri Burns, Executive Director, for the purpose of continuing the post licensing inspection of the facility. During this inspection the LPA requested documents from the staff and client files for the file reviews. While the documents were being pulled, the LPA conducted confidential staff interviews. Due to time constraints, the inspection will have to be completed on a subsequent day. A copy of this report was provided to Lauri Burns.

met_with: Lauri Burns


summary: Facility Evaluation

raw_content:
Narrative:
On 09/28/21 at 10: AM, Licensing Program Analyst (LPA) Belinda Torres and Licensing Program Manager (LPM) Jennifer Smith met with Anasheh Safarian, Administrator, for the purpose of continuing the post licensing inspection of the facility. During this inspection the LPM reviewed five staff files. The LPA conducted confidential staff interviews and partially reviewed one client file. Due to time constraints, the inspection will have to be completed on a subsequent day. A copy of this report was provided to Anasheh Safarian.

met_with: Anasheh Safarian


summary: Facility Evaluation

raw_content:
Narrative:
On 12/02/21 at 10: AM, Licensing Program Analysts (LPAs) Belinda Torres, Lisi Leon, Leslie Covarrubias, and Licensing Program Manager (LPM) Jennifer Smith met with Anasheh Safarian, Administrator, and Michelle Menke, Head of Service, for the purpose of completing the post licensing inspection of the facility. During this post licensing inspection continuation, the LPAs and LPM continued the review of three client files and ten staff files. LPA Torres requested the facility's Emergency Intervention Staff Training and Staffing Requirements from Anasheh which she was unable to provide during this inspection and there was no documentation in the staff files. Due to technical difficulties, LPA Torres was unable to cite the deficiencies. The inspection will have to be completed on a subsequent day and deficiencies will be cited. A copy of this report was provided to Michelle.

met_with: Michelle Menke


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 02/08/22 at 10: AM, Licensing Program Analysts (LPAs) Belinda Torres and Lisi Leon met with Anasheh Safarian, Administrator, Sandy Sandoval, Facility Manager, and Vanessa Zelaya, Direct Care Staff, for the purpose of completing the post licensing inspection of the facility. During this post licensing inspection continuation, the LPAs reviewed the operational requirements and emergency intervention plan. Ten staff files were reviewed. The licensee did not have the documentation available for review by the LPAs for the Emergency Intervention Staff Training and Staffing Requirements and Personnel Records for staff training for the ten out ten safe files reviewed. Based on record review, the licensee did not ensure the facility was in compliance with Emergency Intervention Staff Training and Staffing Requirements. The facility is cited under Interim Licensing Standards, Short Term Residential Therapeutic Program Articles 1 through 10, 87095.65(b)(6), 87095.65(b)(7), 87095.65(c), 87095.65(d), 87095.65(d)(1), 87095.65(d)(1)(A), 87095.65(d)(1)(B), 87095.65(d)(1)(C), 87095.65(d)(2), 87095.66(b), 87095.65(b), 87095.65(b)(1), 87095.65(b)(2), 87095.65(b)(3), 87095.65(b)(5) and Personnel Records 87065(e)(1), Personnel Records 87065(e)(1)(A), 87065(e)(1)(B), 87065.1(C)(1)(A)(2) and 87065(c)(1)(C). The LPA received verbal authorization from Sylvia Steinhart for Vanessa to sign for this licensing report. A copy of this report and the appeal rights was provided to Vanessa.

Deficiencies:
87095.65(b): Emergency Intervention Staff Training

(b) The emergency intervention training curriculum must address the following areas

met_with: Anasheh Safarian, Sandy Sandoval & Vanessa Zelaya


summary: Facility Evaluation

raw_content:
Narrative:
On July 2, 2021, at 12:14pm, Licensing Program Analyst (LPA) Nicole Strickland met with Vera's Sanctuary Head of Service Michelle Menke to deliver a Case Management - Deficiencies report. Information received by Community Care Licensing (CCL) on April 1, 2021 revealed the Needs and Service Plan for Child #1 (C1) was not being updated at least every 30 days as required by Interim Licensing Standards (ILS) regulation 87068.3(a). ILS 87068. Modifications to the needs and services plan (a) The needs and services plan specified in Section 87068.2 shall be updated at least every 30 days to determine the following. Record review was able to provide evidence that C1 had an initial Needs and Service Plan created upon intake in November 2020 however, the facility was unable to provide documentation that any updates to the Needs and Service Plan had been done during the months of December 2020, January 2021, February 2021, or March of 2021. Confidential interviews revealed that the facility had no documentation of NSP's being done during that time period. Confidential interviews and record review further revealed the facility does not allow resident to have or purchase cell phones. Record review revealed that there was no documentation that Child #1 (C1) was not allowed purchase C1's own cell phone. Confidential interviews reported C1 was made to turn in the cell phone. This is a violation of Interim Licensing Standards (ILS) 87072(d)(8)(B). ILS Personal Rights (d)(8)(B) all restrictions shall be documented in the child's needs and services plan or the facility's discipline policies and be signed by the child's authorized representative. Record review could not provide the required documentation LPA observation on July 2, 2021 noted that the facility did not have a designated Facility manager present at the facility while four residents were present. LPA noted that this was a violation of ILS 87065(f). ILS Personnel Requirement (f) The licensee shall designate at lease one Facility Manager to be present a the facility at all times when one or more children are present. ****** Based on confidential interviews and record review of facility documentation the facility is cited for violation of of ILS 87068.3(a) Modification to the needs and service plan, and violation of ILS 87072(d)(8)(B) Personal Rights, and violation of ILS 87065(f). Licensing Program Analyst (LPA) received email authority from Anasheh Sarfarian to allow Michelle Menke to sign on behalf of the facility. A copy of this report and appeal rights was discussed and provided to Head of Service Michellle Menke..


facility_name: VICTOR TREATMENT CENTER - CLOVER HOUSE

raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Cheyenne McCambridge met with Assistant Executive Director Kristine Martinez regarding a complaint investigation at the facility. The purpose of the inspection was to deliver the findings for the above allegation. During the course of the investigation, LPA McCambridge interviewed youth and staff, and reviewed files. During confidential interviews it was determined that no statements were amde to support any of the allegations. A tour of the facility was conducted and there was adequate perishable and non-perishable food supply. This department has investigated the allegations, and although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the above allegations are true; therefore, the above allegations are unsubstantiated. Appeal Rights were provided and discussed and no deficiencies were cited. Exit interview was conducted and a copy of the report was left with the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: Cheyenne McCambridge 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 3

met_with: Kristine Martinez


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Cheyenne McCambridge conducted an unannounced inspection for the purposes of completing a annual/required and met with administrator Kristine Aphugh. Physical Plant was toured inside and out. Water temperatures were measured at 119 degrees. 7 day Non perishable food supply was inspected and was found to be adequate. 2 day perishable food supply was inspected and were found to be adequate and consistent with the alternate menu. Weeks menu was not posted and facility was reminded that this needed to be posted. LPAs inspected bedrooms and found that there was adequate linens and each bed had mattress pads. LPAs completed a tour of the home and outdoor activity area. The home is clean and in good repair. There are no firearms in the facility. There are no open bodies of water on the property. Healthy snacks are provided. Medications/toxics/cleaning solutions are locked. Required documents are posted. Fire drills are conducted monthly, there are charged operable fire extinguishers, hard wired smoke detectors are in the home. Staff and client files were reviewed at the administration office. Per Title Regulations, no deficiencies were cited during this inspection. An exit interview was conducted and a copy of the report was left at the facility.

visit_type: Annual

met_with: Kristine Aphugh


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Cheyenne McCambridge on the above date at 10: AM. During the inspection, LPA McCambridge met with Administrator Kelly Hernandez in the main office. LPA reviewed zero of child's records on site at the facility due to no clients currently being on psychotropic medication. LPAs reviewed zero of child's psychotropic medications and medication records. LPA interviewed zero of children currently taking psychotropic medication. LPA interviewed three of staff on site starting at 2:00 pm. LPA reviewed three of staff personnel files on site at the facility starting at 11: PM. LPA toured of the facility inside and out at 1: PM LPA provided the Summary Report to Kelly Hernandez, Administrator upon completion. No deficiencies are being cited at this time. LPA conducted exit interview with Administrator Kelly Hernandez.

met_with: Kelly Hernandez


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Cheyenne McCambridge conducted an unannounced inspection for the purposes of completing a annual/required and met with administrator Kristine Martinez. Physical Plant was toured inside and out. Water temperatures were measured at 119 degrees. 7 day Non perishable food supply was inspected and was found to be adequate. 2 day perishable food supply was inspected and were found to be adequate and consistent with the alternate menu. Weeks menu was not posted and facility was reminded that this needed to be posted. LPAs inspected bedrooms and found that there was adequate linens and each bed had mattress pads. LPAs completed a tour of the home and outdoor activity area. The home is clean and in good repair. There are no firearms in the facility. There are no open bodies of water on the property. Healthy snacks are provided. Medications/toxics/cleaning solutions are locked. Required documents are posted. Fire drills are conducted monthly, there are charged operable fire extinguishers, hard wired smoke detectors are in the home. Staff and client files were reviewed at the administration office. Per Title Regulations, no deficiencies were cited during this inspection. An exit interview was conducted and a copy of the report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Cheyenne McCambridge on the above date at 10: AM. During the inspection, LPA McCambridge met with Assistant Executive Director in the main office. LPA reviewed zero of child's records on site at the facility due to no clients meeting the criteria for inspection. LPAs reviewed zero of child's psychotropic medications and medication records. LPA interviewed zero of children currently taking psychotropic medication. LPA interviewed two of staff on site starting at 1:00 pm. LPA reviewed two of staff personnel files on site at the facility starting at 10: PM. LPA toured of the facility inside and out at 12: PM LPA provided the Summary Report to Kristine Martinez upon completion. No deficiencies are being cited at this time. LPA conducted exit interview and left a copy of the document at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 10/2/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a random annual inspection. LPA met with Residential Services Supervisor Juan Duran and informed of the purpose of the visit. LPA toured the facility site and observed no immediate safety risks. Bedrooms offer individual beds and are either single- or double-occupancy. Kitchen and bathrooms are maintained in sanitary condition. There is food to meet the requirements of the clients in care. Activity spaces are free of hazards. Knives and chemicals are locked away and made inaccessible to clients. LPA conducted interviews of 2 staff members. All clients were at school during LPA's visit. LPA obtained school address and bell schedule information from staff. LPA reviewed files maintained on site, including emergency drill logs and cash resources, and observed no deficiencies. The remaining client and personnel records are maintained electronically and accessible at the licensee's administrative office. A continuation visit will be conducted to complete this inspection. No deficiency citations were issued at today's visit. LPA observed one area in which technical support may beneficial. See LIC 9102. An exit interview was conducted, appeal rights were provided, and a copy of this report was left with Residential Services Supervisor.


summary: Facility Evaluation

raw_content:
Narrative:
On 10/3/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management - annual continuation visit. LPA met with Assistant Director Kristine Martinez at the licensee's administrative office and informed of the purpose of the visit. LPA reviewed 5 personnel files. Using the CARE Inspection tool, no deficiencies were observed. Files were organized and observed to be complete. All staff have a valid background clearance and have valid first aid certifications. Staff have received training meeting licensing requirements, including intervention and restraint training. A continuation visit will be conducted to complete review of client records and conduct remaining interview(s). No deficiency citations were issued at today's visit. An exit interview was conducted, and a copy of this report was left with Assistant Director.

met_with: Residential Services Supervisor Juan Duran


summary: Facility Evaluation

raw_content:
Narrative:
On 10/16/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management annual continuation inspection. LPA met with Assistant Director Kristine Martinez and informed of the purpose of the visit, which was to continue the annual inspection initiated on 10/2/24. During today's inspection, LPA reviewed 5 client records. Using the CARE Inspection Tool, no deficiencies were observed. LPA observed files to be complete with emergency contact information, signed personal rights and facility policies forms, accurate cash/allowance and medication records, and up-to-date needs and services plans. The final portion of the inspection, client and staff interviews, will be conducted on a later date. An exit interview was conducted, and a copy of this report was left with Assistant Director.

met_with: Assistant Director Kristine Martinez


facility_name: VICTOR TREATMENT CENTER - COUNTRY CLUB HOUSE

raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Brian Bertoli met with Administrator Katie Miller regarding a complaint investigation at the Short-Term Residential Treatment Program. The purpose of the meeting was to deliver the findings for the above complaint allegations. During the course of the investigation, LPA Bertoli inspected the facility, reviewed records, and conducted confidential interviews, which did not indicate conclusively that the above allegations occurred.There is a lack of evidence to make a determination as to whether a regulatory violation did occur. This department has investigated the allegations, and although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that Staff inappropriately restrained minors or Staff bullied minors in care; therefore, the above allegations are Unsubstantiated. Appeal Rights were provided and discussed, and no deficiencies were cited. An exit interview was conducted and a copy of the report was given to the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Brian Bertoli LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Katie Miller


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Brian Bertoli met with Administrator Katie Miller regarding a complaint investigation at the Short-Term Residential Treatment Program. The purpose of the meeting was to deliver the findings for the above complaint allegations. During the course of the investigation, LPA Bertoli inspected the facility, reviewed records, and conducted confidential interviews, which did not indicate conclusively that the above allegations occurred.There is a lack of evidence to make a determination as to whether a regulatory violation did occur. This department has investigated the allegations, and although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that Staff Handles minor roughly; therefore, the above allegations are Unsubstantiated. Appeal Rights were provided and discussed, and no deficiencies were cited. An exit interview was conducted and a copy of the report was given to the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Brian Bertoli 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


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Cheyenne McCambridge conducted an unannounced inspection for the purposes of completing a Annual/Required and met with administrator Kristine Aphugh LPA toured the facility, inside and out. Staff and client files were previously reviewed at the head office on Irwin Lane. The group home is licensed to serve six clients. It has four bedrooms, two rooms are single occupancy. Currently six clients are in placement. LPA observed at the time of this visit, the facility to be clean, safe, sanitary and homelike. Posted in the facility were the facility license, the menu, client's personal rights, facility sketch, facility rules, outing schedule, emergency services listing and other forms. All medications, sharps, personal valuables, client files, and a first aid kit are kept locked in the staff office. Medications are double locked inside the office. There are no fire arms. The facility has a pool with an approved pool cover. All staff are trained in water emergencies. There is a hard wired fire alarm, smoke alarms and a Co detector. The facility has ample fresh and non-perishable food and plentiful fresh fruit is provided for snacks. Residents have access to a land line phone in the house. Per Title Regulations, no deficiencies were cited during this inspection. Exit interview conducted, and a copy of the report was left at the facility with staff.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Cheyenne McCambridge conducted an unannounced inspection for the purposes of completing a Annual/Required and met with administrator Kristine Hernandez. LPA toured the facility, inside and out. Staff and client files were previously reviewed at the head office on Irwin Lane. The group home is licensed to serve six clients. It has four bedrooms, two rooms are single occupancy. Currently six clients are in placement. LPA observed at the time of this visit, the facility to be clean, safe, sanitary and homelike. Posted in the facility were the facility license, the menu, client's personal rights, facility sketch, facility rules, outing schedule, emergency services listing and other forms. All medications, sharps, personal valuables, client files, and a first aid kit are kept locked in the staff office. Medications are double locked inside the office. There are no fire arms. The facility has a pool with an approved pool cover. All staff are trained in water emergencies. There is a hard wired fire alarm, smoke alarms and a Co detector. The facility has ample fresh and non-perishable food and plentiful fresh fruit is provided for snacks. Residents have access to a land line phone in the house. Per Title Regulations, no deficiencies were cited during this inspection. Exit interview conducted, and a copy of the report was left at the facility with staff.

met_with: Kristine Hernandez


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Cheyenne McCambridge on the above date at 1: PM. During the inspection, LPA McCambridge met with Administrator Kristine Martinez in the main office. LPA reviewed one child's records on site at the facility. LPAs reviewed one child's psychotropic medications and medication records. LPA interviewed one client currently taking psychotropic medication. LPA interviewed three of staff on site starting at 2:00 pm. LPA reviewed three of staff personnel files on site at the facility starting at 3: PM. LPA toured of the facility inside and out at 3: PM LPA provided the Summary Report to Kristine Martinez, Administrator upon completion. No deficiencies are being cited at this time. LPA conducted exit interview with Administrator Kristine Martinez.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date Licensing Program Analyst (LPA) Brian Bertoli conducted an unannounced inspection at the facility and met with Residential Services Supervisor Katy Miller regarding Special Incident Reports (SIR) that were submitted to Community Care Licensing. The incidents took place on 05/13/2024 and 05/19/2024, and the SIRs were written to report incidents regarding staff utilizing prone restraints. LPA Bertoli inspected the facility and then discussed the incidents with Supervisor Miller. In the course of reviewing the incidents, Supervisor Miller stated that staff had engaged in prone restraints. Facility was given a Technical Advisory for ILS Version Section 87095.01(a)(4) Emergency Interventions Prohibition. Based on records reviewed and interviews conducted on 06/10/2024, staff was found to have used prone restraints on the youth. The facility was also advised that their Program Statement would need to be revised for all their STRTP facilities to not allow prone restraints, and that staff needs to immediately be informed and re-trained so as not to utilize prone restraints. An exit interview was conducted and a copy of the report and appeal rights were provided to the facility.

met_with: Katy Miller


summary: Facility Evaluation

raw_content:
Narrative:
On 10/2/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a random annual inspection. LPA met with Residential Services Supervisor Katie Miller and informed of the purpose of the visit. LPA toured the facility site and observed no immediate safety risks. Bedrooms offer individual beds and are either single- or double-occupancy. Kitchen and bathrooms are maintained in sanitary condition. There is food to meet the requirements of the clients in care. Knives and chemicals are locked away and made inaccessible to clients. Activity spaces are free of hazards. The backyard pool has a firm, locked cover. LPA conducted interviews of 1 staff member. Clients returned from school at the end of LPA's visit. LPA obtained school address and bell schedule information from staff. LPA reviewed files maintained on site, including medication administration records and cash resources, and observed no deficiencies. The remaining client and personnel records are maintained electronically and accessible at the licensee's administrative office. A continuation visit will be conducted to complete this inspection. No deficiency citations were issued at today's visit. An exit interview was conducted, appeal rights were provided, and a copy of this report was left with Residential Services Supervisor.


summary: Facility Evaluation

narrative: On 10/3/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management - annual continuation visit. LPA met with Assistant Director Kristine Martinez at the licensee's administrative office and informed of the purpose of the visit. LPA reviewed 5 personnel files. Using the CARE Inspection tool, no deficiencies were observed. Files were organized and observed to be complete. All staff have a valid background clearance and have valid first aid certifications. Staff have received training meeting licensing requirements, including intervention and restraint training. A continuation visit will be conducted to complete review of client records and conduct remaining interview(s). No deficiency citations were issued at today's visit. An exit interview was conducted, and a copy of this report was left with Assistant Director.


summary: Facility Evaluation

narrative: On 10/16/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management annual continuation inspection. LPA met with Assistant Director Kristine Martinez and informed of the purpose of the visit, which was to continue the annual inspection initiated on 10/2/24. During today's inspection, LPA reviewed 5 client records. Using the CARE Inspection Tool, no deficiencies were observed. LPA observed files to be complete with emergency contact information, signed personal rights and facility policies forms, accurate cash/allowance and medication records, and up-to-date needs and services plans. The final portion of the inspection, client and staff interviews, will be conducted on a later date. An exit interview was conducted, and a copy of this report was left with Assistant Director.