summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Olivia Rosas made an announced inspection to the Ascend Healthcare 4 on 10/19/21 at 9:00am for the purpose of conducting Pre-licensing Inspection. LPA Rosas met with Staff#1(S1), Staff#2(S2), Staff#3(S3) who granted access to the facility and an inspection of the facility was conducted together. The Ascend Healthcare 3 is a therapeutic treatment program that's designed to accept "Private Placement's" for a length of 45 - 90 days and is licensed to provide care supervision for six (6) youths, ages 12-17 years; ambulatory only. Individuals mention in this report are identify on the Confidential Names List (LIC811) dated 10/19/21. The CEO states that there are no guns or weapons on the premises. This is a two-story home with four (4) bedrooms, two (2) staff offices, four (4) bathrooms, living room, kitchen, media room, group room, living room, dining area, outdoor space with basketball court, detach and attach garages, outdoor barn that be used for Equine Therapy farm. LPA inspected the following: The Laundry room: The laundry room is inside of the attach garage adjacent to the kitchen. The laundry detergent is distributed to children individually according to the load of their laundry. Living Room/Dining Room/Kitchen: Observed to be clean and organized; equip with living room furniture. The Kitchen stove is gas operated range. The sharp knives and chemicals are made inaccessible locked in container in the staff office. There are three (3) extra industrial refrigerators in the garage used for extra storage. LPA observed coverage trash cans in the kitchen, bathroom and staff office. LPA observed ample perishable food items in the refrigerator and the pantry is fully stocked with non-perishable food items. LPA observed enough perishable and Non perishable food items for seven (7) days. The applicant will to ensure that three (3) nutritious meals, snacks, and special snacks will be provided to the youth. All disinfectant/ poisons chemicals are properly stored inaccessible. There is a private chef that comes to the facility and prepares all meals for the youth. Report continues on LIC 809-C Bedroom #1 (upstairs): Is vacant. This room has two queen size beds, adequate closet and drawer space. A door chime will be install for balcony access. Bedroom #2 (upstairs): Is used as office space with a daybed. The room will be used as quarantine room if needed. The bedroom has access to the rooftop/patio. A door chime will be install for rooftop access. Bedroom #3 (upstairs): Is vacant. This room has two queen size beds, adequate closet and drawer space. A door chime will be install for balcony access. Bedroom #4 (upstairs): Is vacant. This room has two queen size beds, adequate closet and drawer space. A door chime will be install for balcony access. There is a bathroom in the room. The bedroom has non working fire place. The room has a walk-in closet inside of the bathroom that has attic access that would be locked. Bathrooms: The bathrooms were inspected and found to be clean. LPA observed S1, S2, S3 test the water temperature, bathroom sinks and ensured that all toilets flushed. Two (2) bathrooms are located downstairs. Bathroom#1 is downstairs upon entering the house and Bathroom#2 is by the kitchen. Bathroom#3 is located upstairs and it has shower, sink, and toilet. Bathroom#4 is located inside of Bedroom#4. Staff Office/Medication Room (downstairs): All the children prescribed medications are locked in the staff office and children files are store in a KIPU software system. Staff office is located inside the downstairs floor. LPA observed a large key locked cabinet that stored hygiene supplies, separate containers for medication, various file folders to maintain the youth's records. The First Aid kit has the required items inside (age-appropriate, and scissors, tweezers, thermometer, and gauzes, antiseptic and First Aid Manual Guide. Only staff has access to this room. Staff Office (downstairs): This room will be used for staff. Staff Office/Intake Room (downstairs): This room will be by administration to conduct intakes. All windows were in good condition with screens and blinds. There were no security bars on the windows. LPA observed ample towels and linen closet. Report continues on LIC 809-C Back yard area/outdoors: There is propane grill in good condition also observed to be secure and safe. The outdoor area has detached garage that be used for storage. Two play houses that be locked and only be used as storage. The backyard has basketball court, tennis court, golf, and barn that will be used for horses. At the moment they have no animals. The backyard has construction that per S1 should be completed by the end of the month. Garages: The attached garage is used as storage and is kept locked. The detached garage outside is locked and will be used as storage. LPA observed two storage bins. Storage bins will be used for storage at the time of the inspection they were empty. and will be kept locked. All windows, screens and blinds from the inside and outside of the facility were observed to be in good condition. Although there was not a vehicle to be inspected. S1 ensured that there will be a facility vehicles available to transport the youth to appointment and offsite extra curriculum recreational activities. S1 will provide the make and model of the vehicle once it is the vehicle obtained. The passageways and porches are unobstructed. All posting requirements were met, (food menu, regulations, licenses, emergency disaster plan, Children's Personal Rights, and Ombudsman). The facility has a working telephone and youths can use the telephone unless restricted by court order. The Emergency Evacuation Plan is posted on the walls throughout the facility. There is a wood burning double sided fireplace; operable but not being utilized. The facility uses NEST electronic combined Smoke detector and Carbon Monoxide. On 08/26/2021, facility was informed that currently Community Care Licensing (CCL) are not approving camera waivers. S1 stated the facility has no security cameras installed. The facility currently has no camera waiver or is granted to use video recording cameras. Department will inform facility when the facility can request camera waiver. Fire Clearance granted on 6/22/2020 indicates that "The facility renders no care to clients. This facility is used for drug and alcohol rehabilitation only. Garages are to be used for stated and vehicle use only, no habitation permitted." LPA Rosas inspected and discussed the use of the garages are only to be used for storage or for cars. During inspection the garages are being used as storage. Report continues on LIC 809-C LPA Rosas during the inspection conducted Component III with S1, S2, S3. LPA Rosas was provided with missing documents. LPA Rosas discussed with and advised If any changes or modifications to the program statement or facility physical plant need to be submitted to the Department for review and approval before implementing the new changes. If the facility wants to use detached or attached garages a new fire clearance will need to be requested with a follow up inspection. The facility will submit a safety plan to add a pool to the backyard. During the inspection the facility does not have a pool. The alarm chime sensor waiver request is pending approval from Community Care Licensing Division (CCLD). LPA Rosas recommended for a provisional license based the inspection of the entire physical plant, inside and out. Pre-Licensing administrative conditions are pending review by LPM JoAnne Griffin. Upon receiving probational license the facility will be placement ready. A review of Facility's Personnel Report Summary on 10/18/2021 indicates that no associations have been made to the facility. There were no deficiencies observed or cited at this time. Exit interview was conducted with S2 and a copy of this report was left at the facility.

visit_type: Prelicensing


state: CA

facility_name: ASCEND HEALTHCARE 4

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Olivia Rosas made an announced inspection to the Ascend Healthcare 4 on 10/19/21 at 9:00am for the purpose of conducting Case Management- Licensee Initiated (Chime Window/Door Waiver). LPA Rosas met with Staff#1(S1), Staff#2(S2), Staff#3(S3) who granted access to the facility and an inspection of the facility was conducted together. The Ascend Healthcare 3 is a therapeutic treatment program that's designed to accept "Private Placement's" for a length of 45 - 90 days and is licensed to provide care supervision for six (6) youths, ages 12-17 years; ambulatory only. Individuals mention in this report are identify on the Confidential Names List (LIC811) dated 10/19/21. The following items were inspected with S1, S2, S3: As indicated on the facility sketch, the facility has a total of four (4) chime alarm sensors installed on the exit glass door in Bedroom#1, Bedroom#2, Bedroom#3 and Bathroom#4 (upstairs) leading to the rooftop/balcony . LPA Rosas and S1, S2, S3 verified the alarm sensors and were operable during the inspection by testing the exit doors. The alarm chime sensor waiver request is pending approval from Community Care Licensing Division (CCLD). There were no deficiencies noted or cited during this inspection. Exit interview was conducted with S2 and a copy of this report was left at the facility

report_type: Facility Evaluation

visit_type: Case Management

met_with: Staff#1 (S1)


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 01/20/ Licensing Program Analyst (LPA) Bernice Karnsrithong arrived at the facility to conduct a required post licensing inspection. LPA Karnsrithong met with Director of Operations, Jaq Waldron who granted access to the facility and provided the tour. The facility is licensed to provide care and supervision for six (6) youths, ages 12-17 years; ambulatory only. The facility is located in a residential community. The facility provides drug and alcohol rehabilitation and mental health services for male clients only. The facility is gated and fenced in. The front entryway is being used for COVID-19 check in. There are four (4) fire extinguishers throughout the facility and a NEST Fire/Carbon Monoxide Detectors and Alarms throughout the house. During the inspection LPA Karnsrithong has observed the following: Living Room/Common Room: There are three (3) living rooms/common room located downstairs for clients to use. All three living rooms have couches, a table and a rug. This area is used for group activities and therapeutic sessions. The main living room is attached to the kitchen and has a desk, a television, and a book shelf with books and games for clients to use. Outdoor Area: The entire outside area is fenced in. Water and electric shut off valves are located in the front of the house. The gas shut off utility valve is located next to the gate up front. The front lawn has grass and trees. There is a outdoor patio seating with a tree and a swing located in the front yard. The backyard is fenced in and gated. It has a barn with three (3) goats, one (1) sheep and three (3) horses. There is also a chicken coop and a closed in nursery garden in the backyard. There are two (2) outside sheds to be utilized as storage next to the barn. The backyard has a basketball court, tennis court, batting cages and a skate park. The backyard has a covered deck seating that has a propane grill that is secured and safe. (Page 1 of 3) Kitchen/Dining Room Area: The kitchen and dining room area is observed to be clean and well-maintained. A chef was observed preparing meals for the clients in the main kitchen. Menus are posted in the kitchen. LPA observed ample perishable food items in the refrigerator and the pantry is fully stocked with non-perishable food items. There is stove, refrigerator, microwaves, toaster, air fryer, and blender in the kitchen. There is a trash can with a tight fit lid in the kitchen area. There is also a working sink in the main kitchen. Pots, pans, utensils, dishes, and cups are stored in the kitchen. There is a separate kitchen area being used to prepare Kosher meals. It has its own portable stove, microwave, pots, pans, utensils, dishes, and cups. This kitchen has its own sink as well. There is also a nook bar that can be used for dining in the kosher kitchen. The dining room has a long table with ample seating for clients and staff. Office Room: There are three (3) office rooms located downstairs. One office room is being used by administrative staff and is located at the back of the house. It has wall shelf units, an office desk, and chairs. Another office room is being used for therapeutic services. It has couches, coffee table, an office desk, chairs, and a computer. This room has two doors connecting it to the other hallway next to the client downstairs bathroom. One of the doorknobs in this office room is loosed. Another office room is in front of the therapy room. It has a sink, an office desk, chairs, printer, and laptop. It has cabinets that stores medication, hygiene supplies, first aid kit, and medical supplies. It also has a refrigerator that is being used for storing medications if needed. Nursing staff also maintain and monitor the medications, health supplies, and first aid kit. All the children prescribed medications are locked in the staff office and children files are store in a KIPU software system. Staff also uses the cabinets in this room as storage for their personal items. There is a coffee maker inside this office for staff to used. All office rooms are kept locked when not in used. Garages: The attached garage is used as storage for food items and supplies and is kept locked at all times. It has a refrigerators, freezer and a pantry shelf. The laundry room is also located in this garage. There is a detached garage in the facility that is currently being used as an education and art therapy room. There are six (6) computers, tables and chairs for clients to use. There is a driveway outside the detached garage where the facility vehicle is parked at. The facility vehicle is in good working condition. (Page 2 of 3) Bedrooms: There are four (4) bedrooms all located upstairs. One (1) bedroom is currently being used as a quarantine room for COVID and a therapy room if needed. This room has a daybed. All rooms are equipped with full sized beds, adequate closet, and drawer space and adequate lighting. Each room has a patio balcony that has double wooden doors and double screen doors. There is a master bedroom that has a couch and a full-sized bed. The master bedroom has its own bathroom with a toilet, shower, and a tub. The clients are not using the tub and inaccessible. There is walk-in closet that is kept locked in the master bedroom that will be used for storage. There are cabinets located next to the bedrooms being used for storing linens and client's contraband items that is kept locked at all times. Each bedroom has its own facility sketch plan, client schedule, and emergency disaster plan. One bedroom has a broken and ripped screen. A door chime will be installed for patio balcony access. Bathrooms: There are four (4) bathrooms in the facility. Two (2) bathrooms are located downstairs. One is being used by staff only and is kept locked. The staff bathroom has a working toilet and sink. Another bathroom next to the therapy room is used by clients. It has a toilet, sink, and a shower. The shower is not being used. Upstairs there are two (2) bathrooms being used by clients. Both client bathrooms have a shower, double sinks, and a toilet. The faucet in the main client bathroom is loosed and not securely attached. Laundry room: The laundry room is inside of the attach garage adjacent to the kitchen. Laundry supplies are kept in the laundry room. Clients may use the washer and dryer under staff supervision. There are deficiencies cited at this time based on the following regulations: Title Division Section 80088(e)(3): All toilets, hand washing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items. Title Division Section 80087(a): 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. Title Division Section 80088(b): All window screens shall be in good repair and be free of insects, dirt and other debris. Plan of correction was discussed with licensee. Exit interview was conducted and a copy of this report will be provided to the facility via email. (Page 3 of 3)

Deficiencies:
84088(b): Fixtures, Furniture, Equipment, and Supplies

(b) As a condition of licensure, toilets, wash basin, bath and shower fixtures shall, at a minimum, meet the following requirements

met_with: Director of Operations


summary: Facility Evaluation

raw_content:
Narrative:
On 02/04/2022 at 10am, Licensing Program Analyst (LPA) arrived at the facility for the purpose of conducting a Plan of Correction (POC) visit. LPA Karnsrithong met with Facility Manager, Zachary Hale who granted access and tour of the facility. The current census of the facility is four (4). During the visit there were four (4) staff on site. Currently there are two (2) positive cases of COVID-19 during the visit. The clients tested positive on 02/01/2022 and are currently being quarantined. During the visit, LPA Karnsrithong observed that the facility is observing COVID-19 protocols by taking temperatures of all guests and staff coming in to the facility. All staff and clients are wearing surgical masks. There is a COVID-19 sign in at the doorway. LPA Karnsrithong had observed that the bedroom #3 window screened is in good repair. The faucet in the client bathroom upstairs is also in good repair and securely bolted in to the sink. The door knob in the Office/Therapy Room is securely attached and in good repair. The facility has met the requirements for the Plan of Corrections. No deficiencies were cited at this time. Exit interview was conducted with Facility Manager and a copy of this report will be provided to the facility.

met_with: Facility Manager


facility_name: ASCEND HEALTHCARE 5

summary: Facility Evaluation

raw_content:
Narrative:
On 10/20/2022 10:30am Licensing Program Analyst (LPA) Rosslyn Gray made an unannounced to ASCEND HEALTHCARE 5 for the purpose to conduct the Prelicensing Inspection. LPA met with the Program Administrator, who granted access into the home, and who provided a tour of the entire physical plant inside and out. The facility is licensed to care for up to six (6) Male and Female children, ages 12-17 years, Ambulatory only. The facility acquired Accreditation of Rehabilitation Facilities Joint Commission valid through 03/20/2024. Staff confirmed that there are no firearms or dangerous weapons in the facility. Group Home Overview: This is a (1) story Group Home facility. There is two (2) car garage that has been converted to a supply storage room. There are total of four (4) operable fireplaces throughout the facility. All are were observed to be secure screens. The Location of the fireplaces are in the medical room, bedroom #1, living room and the group room. There are currently no children in placement. BEDROOMS: All three (3) bedrooms are equipped with comfortable beds, mattresses, linen, blankets and pillows. There are chimes on the exit doors.The Administrator provided a notice of door chimes that are installed in each room.The alarms active to alert when doors open. Bedroom # Currently unoccupied, equipped with a King-size and Queen size bed adequate drawer space (built in shelves and pull-out drawers, and a walk-in bathroom (toiled bidet, large walk-in shower, two (2) sinks and ample storage space. Bedroom #2: Currently unoccupied equipped with a two (2) twin sized beds adequate drawer space (built in shelves) and three (3) open door closets. Bedroom# Currently unoccupied, equipped with two (2) Full size bed and adequate drawer space (built in shelves). BATHROOMS: All were inspected and found to be clean. LPA test the water temperature, bathroom sinks and ensured that all toilets flushed and bathroom #1 has a Bidet. The water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. Bathroom #1 is located inside #1 and #2 is located to the left of the hallway near bedroom #2 and #3. Living Room: is equipped with 2 sectional sofas, three (3) coffee tables, a television and a securely covered fireplace. Dining Room: equipped with a large table with six (6) chairs and ample lighting. Kitchen: LPA observed the monthly/weekly menu posted on the wall. The kitchen. equipped with a double door refrigerator with a bottom freezer, an island stove with two(2)ovens, a six (6) functional gas burners. There is plenty of cabinet space, a locked box for knives and sharp objects. A weekly menu was observed and posted in the kitchen and food service adequate for breakfast, and snacks, lunch and dinner. Meals are prepared by a Private Chef. Laundry area is located near the dining room. The laundry detergent and other cleaning supplies are stored in a locked cabinet about the washer and dryer unit. The locked pantry is located adjacent to the washer and dryer unit. Chemicals and cleaning solutions are kept in locked cabinets located in the laundry room. The Administrator activated the Nest Carbon Monoxide combined smoke detector was observed and functional. LPA observed six (6) fully charged fire extinguishers located throughout the facility. The Clinical Building. This is a large two (2) story. The Clinical office is furnished with two (2) desk and storage closet for the therapist. The group room is equipped with a three (3) sofas, a large chair, a large storage closet a sink, a double burner, bathroom with 1 sink and disconnect steam room. The school is located on the 2nd floor currently under construction and will not be utilize until complete and inspected. The Administrator provided a site construction safety plan. LPA observe listed on the facility sketch as a classroom and cleared by the Fire Inspector on 08/31/2022. Medication Room: Adjacent to bathroom #1 is locked, entry is to the outside left side of building. This room is equipped with office furniture; two (2) desk two (2) chairs, locked med cabinets. LPA observed a large locked First Aid box mounted on the wall, equipped, complete with scissors, tweezers, thermometer, gauzes, antiseptic and 1st Aid Manual. There is also a small refrigerator for storage of client medication that requires refrigeration. The outdoor perimeter area: The large outdoor area space free of obstructions surrounded with several historical trees. The front, and all exits were observed to be free and clear of hazards and obstruction. LPA observed all windows, screens, blinds, and drapes from the inside and outside were observed to be in good condition. There are no security bars on the windows. Sheds: There is shed for lawn care tools, there is Animal Assisting Shed for the Eco therapist. Tennis court, garden area, a three (3) stall stable that houses four (4) goats, two(2) sheep and a one (1) large pig. There is a composting bin. Pool area: The is a eight feet (8) swimming pool and a shed that has a pool pump and pool supplies that meets regulations. Located in the backyard, there is a fenced and gated pool on the premises that meets regulations. Licensee will ensure that individual supervising children in the pool area is Water Safety trained. Facility appears to be clean, safe, sanitary, and in good repair. There is Koi Pond located at the entrance of the facility inspected and with an approved net covering and a Jacuzzi located near the Clinical Building. The Administrator displayed were the gas shut-off valves are located at the end of driveway and water shut-off valve located outside back of the facility near the Medication room. All posting requirements and Emergency Plan were observed. Children will be accorded personal rights.The grievance Procedure and Personal Rights; are posted on the wall. Children are not restricted to make phones calls to family and or authorized representative. Client will be permitted to make phones calls and stored on electronic program. The Administrator will ensure to utilized the Unusual Incident Report LIC 624, and LIC 624LE to document incidents. Clients Records: Child's Needs and Services plans will be electronically stored in the facilities online Portal with Kipuworks.com electronically stored. Staff Records are electronically stored in the ISolved system. LPA thoroughly reviewed three (3) the records of active primary staff; Program Administrator, Director of Facilities and the Facility Manager, There were no deficiencies cited at this time. LPA concluded the Pre license Inspection. An Exit interview was conducted, and a copy of this report was left at the facility with the Program Administrator

met_with: ADMINISTRATOR


summary: Facility Evaluation

raw_content:
Narrative:
On March 23, 2023, at 9: AM, Licensing Program Analyst (LPA) Charmetha White made an unannounced visit to Ascend Healthcare 5, for the purpose of conducting a Post Licensing Inspection. LPA met with Brenda Reyes, Facility Manager who granted access to the facility and together a tour of the entire interior and exterior physical plant was conducted. The facility is a private pay Group Home running a therapeutic treatment program licensed to provide care and supervision services for up to six (6) male and female children, ages 12-17 years old, ambulatory only. The facility acquired a Rehabilitation Facilities Joint Commission Accreditation which is valid through 03/20/2024. Staff confirmed there are no firearms or dangerous weapons on the premises. The census at the time of the inspection was six (6). The Group Home is set up as follows: This is a single-story, three (3) bedrooms, 2 bathrooms house which includes: Living room, Dining room, Kitchen, Laundry area, Medication room, Detached Clinical Building, Equine Therapy farm, Outdoor space, and a Detached Garage. Living Room: is equipped with 2 sectional sofas, three (3) coffee tables, a television and a securely covered fireplace. Dining Room: is equipped with a large table with six (6) chairs. Kitchen: is equipped with a double door refrigerator/freezer, six (6) burner gas operated stove (all burners were operable at the time of the inspection), two (2) ovens, a dishwasher, a trash compactor, a microwave, and a coffee machine. LPA observed the kitchen to have pots, pans, utensils, dishes, cups, plenty of cabinet space, the weekly menu was posted, and the knives and sharps were in a locked kitchen cabinet to the left of the refrigerator. There was an adequate supply of food and meals are prepared offsite by a Private Chef and brought over to the home. Laundry area is located along the hall leading to the side of the house and includes one (1) washer and one (1) dryer. Laundry detergent is kept locked in cabinets above the washer and dryer. Additionally, this area has an exit door which opens to the side of the facing the stairs of the clinical building. There is also a separate small room adjacent to the washer and dryer, which remains locked at all times. LPA observed the room to have a sink and it is used to store extra supplies, chemicals, and cleaning solutions. Report continued on LIC 809C (Page 1 of 3). Medication Room: is located next to bathroom #1 and is only accessible through an entry at the back of the house. The room is equipped with two (2) desks, two (2) chairs, locked cabinets that store medication and medical supplies. There is a First Aid box mounted on the wall, that LPA observed to be equipped with scissors, tweezers, gauzes, and antiseptic, and a digital thermometer. The room also contains a small locked refrigerator to storage client medication that requires refrigeration. The Clinical Building. This is a two-story building located next to the house. The first floor is used as a classroom which is equipped six (6) desks, computers, chairs, a long table, cabinets observed to be used for extra school/classroom supplies, and a bathroom. The bathroom contains a sink and a toilet. There is also a separate office next to the classroom. This room is used by the therapist as a group room and contains a desk, chair, a sofa, and a closet. The second floor is equipped with a conference desk, multiple chairs, storage closets, and a small bathroom. The bathroom contains a toilet, a sink, and a door which opens to an unfinished closet. Equine Therapy Farm: has a barn with four (4) goats, two (2) sheep, two (2) horses, one (1) pig, and a chicken coop. Outdoor space: contains a Koi pond, pool/jacuzzi, and a tennis/basketball court. LPA observed the pool area to fenced and gated to meet regulations. There is also a shed in the backyard that contains the pool pump and pool supplies. The Koi Pond is located at the entrance of the house and was equipped with an approved net covering. Detached Garage: LPA observed the garage to be used for extra storage. Bedrooms: Bedroom #1: is equipped with one (1) King-size bed and one (1) Queen size bed. The room has adequate drawer space, built in shelves, pull-out drawers, double patio doors leading to the side of the house, and a walk-in bathroom. The bathroom has double sinks, a section containing a toilet and a bidet, and a separate section containing a walk-in shower. LPA observed a walk-in closet located in the bathroom which remains locked at all time and it is used for storage. Bedroom #2: is equipped with two (2) Twin sized beds and has adequate drawer space, three closets, and built in shelves. Bedroom#3 is equipped with two (2) Full size beds and has adequate drawer space and built in shelves. LPA observed all three (3) bedrooms to have comfortable mattresses, linens, blankets, and pillows. Each room has door chimes installed on the exit doors tht sounds an alarm when the door opens. Bathrooms: Bathroom #1: is located inside of bedroom #1. Bathroom #2: is located along the hallway catacorner to the kitchen and near bedroom #1 and #2. Report continued on LIC 809C (Page 2 of 3). Additionally, there are two (2) other bathrooms located in the detached clinical building. All bathrooms were inspected and found to be in good repair and working order. The hot water temperature was tested and found to be between 105-120 degrees (F). The carbon monoxide and smoke detectors were tested and found to be in working order. First Aid Kit was checked and found to be complete. The facility has six (6) regulation fire extinguishers. The facility has a working telephone readily accessible. Temperatures in client rooms and common areas were found to be between 68 - 85 degrees (F). Disinfectants/cleaning solutions and poisons are stored and inaccessible to clients. LPA observed the facility to be clean, safe, sanitary and in good repair. The outdoor spaces were clean and clear of hazards. Passageways, open porches, and all exits were observed to be unobstructed. There were no security bars on the windows. Licensee ensures that individuals supervising children in the pool area is Water Safety trained. The facility operates within license conditions and limitations including capacity limitations. LPA discussed and advised the Licensee to ensure the following: Children are afforded their Personal Rights. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. All posting requirements for Group Home Licensure, including the Emergency Plan, and grievance procedure were met and posted on the wall. The LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. Licensee will ensure to utilize the Unusual Incident Report LIC 624, and LIC 624LE to document incidents. Facility Manager provided LPA with a copy of the Personnel Report (LIC 500). LPA will return at a later time to review client and staff records. There are no deficiencies observed or cited at this during this inspection. Exit interview was conducted with the Facility Manager, and a copy of this report was left at the facility. (Page 3 of 3).

met_with: Facility Manager - Brenda Reyes


summary: Facility Evaluation

raw_content:
Narrative:
On October 30, 2023, at 10: AM, Licensing Program Analyst (LPA) Charmetha White made an unannounced visit to Ascend Healthcare 5, for the purpose of conducting an Annual/Required Inspection. LPA met with Brenda Reyes, Facility Manager who granted access to the facility and together a tour of the entire interior and exterior physical plant was conducted. The facility is licensed to provide care and supervision services for up to six (6) male and female children, ages 12-17 years old, ambulatory only. The facility's Rehabilitation Facilities Joint Commission Accreditation is valid through 03/20/2024. There a no firearms or dangerous weapons on the premises. The census at the time of the inspection was six (6). The Group Home is set up as follows: This is a single-story, three (3) bedrooms, 2 bathrooms house which includes: Living room, Dining room, Kitchen, Laundry area, Medication room, Detached Clinical Building, Equine Therapy farm, Outdoor space, and a Detached Garage. Living Room: is equipped with sectional sofas, coffee tables, a television and a securely covered fireplace. Dining Room: is equipped with a large table with six (6) chairs. Kitchen: is equipped with a double door refrigerator/freezer, a built-in six (6) burner gas operated stove (all burners were operable at the time of this inspection), two (2) ovens, a dishwasher, a trash compactor, a microwave, and a coffee machine. LPA observed the kitchen to have pots, pans, utensils, dishes, cups, and plenty of cabinet space. LPA observed the knives and sharps locked in a kitchen cabinet located to the left of the refrigerator and the weekly menu was posted. The facility had adequate perishable and non-perishable food on-site and meals are prepared offsite by a Private Chef and brought over to the home. Laundry area is located along the hall and includes one (1) washer and one (1) dryer. Laundry detergent is kept locked in cabinets above the washer and dryer. Additionally, this area has an exit door that opens to the side of the home. There is a separate small room adjacent to the washer and dryer, which is locked at all times. LPA observed the room to have a sink and it is used to store extra supplies, chemicals, and cleaning solutions. Medication Room: is adjacent to bathroom #1 and is only accessible through an entry at the back of the house. The room is equipped with a desk, chairs, a locked cabinet that stores medication and medical supplies and a small, locked refrigerator to store medication requiring refrigeration. LPA observed the room to have a First Aid box mounted to the wall. Report continued on LIC 808C (page 1 of 3) The Clinical Building. This is a separate two-story building adjacent to the main house. The first floor is used as a classroom that is equipped with six (6) desks, computers, chairs, a long table, cabinets observed to be used for extra school/classroom supplies, and a bathroom. The bathroom contains a sink and a toilet. There is a separate office next to the classroom, that is used by the therapist as a group/therapy office. The office contains a desk, chairs, a sofa, a closet which is used for storage, and a small bathroom. The bathroom contains a toilet, a sink, and a shower. The second floor is equipped with a conference desk, multiple chairs, storage closets, and a small bathroom. The bathroom contains a toilet, a sink, and a door which opens to an unfinished closet. Equine Therapy Farm: has a barn, goats, sheep, horses, a pig, and a chicken coop. Outdoor space: contains a Koi pond near the front entrance and is equipped with an a net covering, a pool/jacuzzi on the side of the home which is fenced and gated to meet reguluations, and a tennis/basketball court in the back of the home. Detached Garage: LPA observed the garage to be used for extra storage. Small shed: located behind the clinical building which is used to store maintenance supplies. Bedrooms: Bedroom #1: is equipped with one (1) King-size bed and one (1) Queen size bed. The room has adequate drawer space, built in shelves, and pull-out drawers. The room has double patio doors leading to the side of the house, and a walk-in bathroom. The bathroom has double sinks, a toilet and a bidet, and a separate enclosure containing a walk-in shower. There is a walk-in closet located in the bathroom that is used for storage and remains locked at all times. Bedroom #2: is equipped with two (2) Twin sized beds. The room has adequate drawer space, three closets, and built in shelves. Bedroom#3 is equipped with two (2) Full size beds. The room has adequate drawer space and built in shelves. LPA observed all three (3) bedrooms to have comfortable mattresses, linens, blankets, pillows, and adequate lighting. Bathrooms: Bathroom #1: is located inside of bedroom #1. Bathroom #2: is located along the hallway near the the kitchen and bedroom #1 and #2. Report continued on LIC 809C (page 2 of 3) Additionally, there are two (2) other bathrooms located in the detached clinical building. All bathrooms were inspected and found to be in good repair and working order. The hot water temperature was tested and found to be between 105-120 degrees (F). The carbon monoxide and smoke detectors were tested and found to be in working order. First Aid Kit was checked and found to be complete. The facility has six (6) regulation fire extinguishers. The facility has a working telephone readily accessible. Temperatures in client rooms and common areas are maintained by a central air and heating system and the home was found to be between 68 - 85 degrees (F). Disinfectants/cleaning solutions and poisons are stored and inaccessible to clients. LPA observed the facility to be clean, safe, sanitary and in good repair. The outdoor spaces were clean and clear of hazards. Passageways, open porches, and all exits were observed to be unobstructed. There were no security bars on the windows. Licensee ensures that individuals supervising children in the pool area is Water Safety trained. The facility operates within license conditions and limitations including capacity limitations. All posting requirements for Group Home Licensure, including the Emergency Plan, Personal Rights, and Grievance Procedures were met and posted on the wall. LPA discussed the following: Children are afforded their Personal Rights. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. LPA reiterated the importance of reporting and submitting Incident Reports, Law Enforcement contact, and reporting all changes within the facility to Community Care Licensing and any other appropriate agencies. The Administrator will ensure the Unusual Incident Report LIC 624, and LIC 624LE forms are utilized to document incidents. Clients Records are electronically stored in the facilities online Portal with Kipuworks.com Staff Records are electronically stored in the ISolved system. Facility Manager provided LPA with a copy of the Personnel Report (LIC 500). LPA will return at a later date to review client and staff records. There are no deficiencies observed or cited at this during this inspection. Exit interview was conducted with the Facility Manager, and a copy of this report was left at the facility. (Page 3 of 3)

visit_type: Annual

met_with: Brenda Reyes - Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 10/31/2023 at 9: AM, Licensing Program Analyst (LPA) C. White, made an announced visit to Ascend Healthcare 5, for the purpose of conducting a Case Management Annual Continuation Inspection. LPA met with Facility Manager, Brenda Reyes. LPA was granted access to the facility and provided the requested information. The facility keeps clients records electronically stored in an online system call KIPUERM and staff Records are electronically stored in the ISolved system. LPA reviewed the following records during the inspection: Client Records: The program currently has a total of six (6) clients. LPA reviewed all six client records and found each record to meet required regulations. Staff Records: The program currently has a total of fourteen (14) staff. LPA reviewed a total of five (5) staff records and confirmed files contained staff qualifications, current CPR/First Aid cards, health screening, and TB test results. LPA obtained the LIC 500 to verify Staff to Client ratio. LPA reviewed the Facility Profile and Personnel Report and confirmed that personnel have required criminal record clearance: DOJ, FBI and Child Abuse; which meet qualification. LPA conducted interviews with five (5) clients and a total of two (2) staff. This inspection included an overview of required Core Services and Supports and based upon inspection of facility records and interviews of staff and clients. Licensee is meeting all requirements. There were deficiencies cited per California Code of Regulations and Interim Licensing Standards. Exit interview was conducted, Appeal Rights and a copy of this report was given to the Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On November 20, 2024, at 10: AM, Licensing Program Analyst (LPA) C. made an unannounced visit to Ascend Healthcare 5, for the purpose of conducting an Annual/Required Inspection. LPA met with Brenda Reyes, Facility Manager who granted access to the facility and together a tour of the entire interior and exterior physical plant was conducted. The facility is licensed to provide care and supervision services for up to six (6) male and female children, ages 12-17 years old, ambulatory only. There a no firearms or dangerous weapons on the premises. The census at the time of the inspection was six (6). The Group Home is set up as follows: This is a single-story house that includes three (3) bedrooms, 2 bathrooms, a living room, dining room, kitchen, laundry area, and a detached two (2) car garage. The home also includes a medication room, a detached clinical building, an equine therapy farm, and outdoor space. Living Room: is equipped with sofas, coffee tables, a mounted television and a covered fireplace. Dining Room: is equipped with a large table with six (6) chairs. Kitchen: is equipped with a double door refrigerator with a bottom freezer, an island stove with six (6) functional gas burners and two (2) ovens, a dishwasher, a trash compactor, a microwave, a coffee machine, an electric ice machine, pots, pans, eating utensils, dishes, and cups. LPA observed the knives and sharps locked in toolbox and kept in a locked kitchen cabinet located to the left of the refrigerator. LPA observed the food menu posted. The facility had the required 2 days of perishable/1 week of non-perishable food supply on the premises and meals are prepared offsite by a Private Chef and brought over to the home. Laundry Area: is adjacent to the kitchen and includes one (1) washer and one (1) dryer. Laundry detergent and cleaning supplies are kept locked in cabinets located this area. The laundry area has an exit door that opens to the side of the home. Additionally, the laundry area has a pantry that is kept locked at all times. LPA observed the pantry to have a sink and it is used to store additional chemicals and cleaning solutions. Detached Garage: LPA observed the garage to be used for extra storage. Report continued on LIC 809C (Page 1 of 3). Medication Room: is only accessible through an entry at the back of the house and is kept locked when not in use. The room is equipped with a desk, chairs, a locked medication cabinet which stores medication, medical supplies, and first aid supplies. The room has a small locked refrigerator to store medication requiring refrigeration. The room has an additional mounted First Aid box complete with tweezers, scissors, gauzes, and antiseptic. Clinical Building. This is a separate two-story building adjacent to the main house. The first floor is used as a classroom that is equipped with six (6) desks, computers, and chairs. The room has a large storage closet which remains locked at all times. LPA observed the cabinet to have extra school/classroom supplies. The room contains a bathroom with a sink and a toilet. There is a separate office next to the classroom, used by the therapist as a group/therapy office. The office contains a desk, chairs, a sofa, a closet which used for storage. The second floor is equipped with a conference desk, multiple chairs, storage closets, and a small bathroom. The bathroom contains a toilet, a sink, and a door which opens to an unfinished closet. Equine Therapy Farm: has a barn, goats, sheep, horses, a pig, and a chicken coop. Outdoor space: the home has a large outdoor space that contains a Koi pond near the front entrance and is equipped with an a net covering; a pool on the side of the home which is fenced and gated to meet regulations; a jacuzzi equipped with a net covering, and a tennis/basketball court in the back of the home. Small shed: located behind the clinical building which is used to store maintenance supplies. Bedrooms: Bedroom #1: is equipped with one (1) King-size bed and one (1) Queen size bed. The room has adequate drawer space, built in shelves, and pull-out drawers. The room has a walk-in bathroom. The bathroom has double sinks, a toilet and a bidet, and a separate enclosure containing a walk-in shower. There is a walk-in closet located in the bathroom that is used for storage and remains locked at all times. Bedroom #2: is equipped with two (2) Twin sized beds. The room has adequate drawer space, three closets, and built in shelves. Bedroom#3 is equipped with two (2) Full size beds. The room has adequate drawer space and built in shelves. LPA observed all three (3) bedrooms to have linens, blankets, pillows, and working lights. Bathrooms: Bathroom #1: is located inside of bedroom #1. Bathroom #2: is located along the hallway near the the kitchen and bedroom #1 and #2. Report continued on LIC 809C (Page 2 of 3). Additionally, there are two (2) other bathrooms located in the detached clinical building. All bathrooms were inspected and found to be in good repair and working order. The hot water temperature was tested and found to be between 105-120 degrees (F). The carbon monoxide and smoke detectors were tested and found to be in working order. The facility has six (6) regulation fire extinguishers. The facility has a working telephone readily accessible. Temperatures in client rooms and common areas are maintained by a central air and heating system and the home was found to be between 68 - 85 degrees (F). LPA observed the facility to be clean, safe, sanitary and in good repair. The outdoor spaces were clean and clear of hazards. Passageways, open porches, and all exits were observed to be unobstructed. There were no security bars on the windows. Licensee ensures that individuals supervising children in the pool area is Water Safety trained. The facility operates within license conditions and limitations including capacity limitations. All posting requirements for Group Home Licensure, including the Emergency Plan, Personal Rights, and Grievance Procedures were met and posted on the wall. LPA discussed the following: Children are afforded their Personal Rights. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. LPA reiterated the importance of reporting and submitting Incident Reports, Law Enforcement contact, and reporting all changes within the facility to Community Care Licensing and any other appropriate agencies. The Administrator will ensure the Unusual Incident Report LIC 624, and LIC 624LE forms are utilized to document incidents. Clients Records are electronically stored in the facilities online Portal with Kipuworks.com Staff Records are electronically stored in the ISolved system. Facility Manager provided LPA with a copy of the Personnel Report (LIC 500) and a current Client Roster (LIC 9020). LPA will return at a later date to review client and staff records. There are no deficiencies observed or cited at this during this inspection. Exit interview was conducted with the Facility Manager, and a copy of this report was left at the facility. (Page 3 of 3).


summary: Facility Evaluation

raw_content:
Narrative:
On November 17, 2025, at 9:30am Licensing Program Analyst (LPA) Emelyn Sanchez P. made an unannounced visit to Ascend Healthcare 5 for the purpose of conducting an Annual/Required Inspection visit. LPA Sanchez P. met with Brenda Reyes, Regional Operations Manager who granted access to the facility. LPA Sanchez P. toured the interior and exterior of the facility. The facility is licensed to provide care and supervision services for up to six (6) children, ages 12-17 years old, ambulatory only. There is a swimming pool on the premises which meets licensing regulations. The census at the time of the inspection was six (6). The facility is a single-story house that includes three (3) bedrooms, 2 bathrooms, a living room, a dining room, kitchen, laundry area, and a detached two (2) car garage. The home also includes a medication room, a detached clinical building, a farm, and outdoor space. The facility is set up as follows: Living Room: is furnished with sectional sofas, a coffee table, a mounted television and a covered fireplace. Dining Room: is equipped with a round table with seven (7) chairs. Kitchen: is equipped with a double door refrigerator with a bottom freezer, an island/stove with six (6) functional gas burners and two (2) ovens, a dishwasher, a non-operating trash compactor, a microwave, a coffee machine, an electric ice machine, pots, pans, eating utensils, dishes, and cups. LPA Sanchez P. observed the knives and sharps locked in a toolbox and kept in a locked kitchen cabinet located to the left of the refrigerator. Report Cont. on LIC 809-C. Pg. 1 of LPA Sanchez P. observed the food menu to be posted. The facility had the required nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days on the premises. LPA Sanchez P. was informed that meals are prepared offsite by a Private Chef and brought over to the home. Laundry Area: is adjacent to the kitchen and includes one (1) washer and one (1) dryer. Laundry detergent and cleaning supplies are kept locked in cabinets located in this area. The laundry area has an exit door that opens to the side of the home. Additionally, the laundry area has a room that is kept locked at all times. LPA Sanchez P. observed the room to have a sink and it is used to store additional chemicals and cleaning solutions. Detached Garage: LPA Sanchez P. observed the garage to be used as a maintenance office space and for extra storage. Medication Room: is only accessible through an entry at the back of the house and is kept locked when not in use. The room is equipped with a desk, chair, locked medication cabinets which store medication, medical supplies, and first aid supplies. The room has a small locked refrigerator to store medication requiring refrigeration. The room has an additional complete mounted First Aid box. Clinical Building: This is a separate two-story building adjacent to the main house. The first floor is used a classroom that is equipped with desks, computers, and chairs. The room has a large storage closet which remains locked at all times. LPA Sanchez P. observed the cabinets to have extra school/classroom supplies. The room contains a bathroom with a sink and a toilet. There is a separate office next to the classroom, used by the therapist as a group/therapy office. The office contains a desk, chair, a sofa, a closet which is used for storage. The second floor is equipped with a conference desk, multiple chairs, storage closets, and a small bathroom. The bathroom contains a toilet, a sink, and a door which opens to a locked closet. Outdoor Space: the home has a large outdoor space that contains a Koi pond near the front entrance and is equipped with an a net covering; a pool on the side of the home which is fenced and gated to meet licensing regulations; a jacuzzi equipped with a net covering, and a tennis/basketball court in the back of the home. Report Cont. on LIC 809-C. Pg. 2 of Farm: has a barn with four (4) goats, three (3) horses, one (1) pig and a chicken coop. Small shed: located behind the clinical building which is used to store maintenance supplies. Bedrooms: Bedroom #1: is equipped with one (1) king-size bed and one (1) queen size bed. The room has adequate drawer space, built in shelves, and pull-out drawers. The room has a walk-in bathroom. The bathroom has double sinks, a toilet and a dubai, and a separate enclosure containing a walk-in shower. There is a walk-in closet located in the bathroom that is used for storage and remains locked at all times. Bedroom #2: is equipped with two (2) twin sized beds. The room has adequate drawer space, three closets, and built in shelves. Bedroom#3: is equipped with two (2) full size beds. The room has adequate drawer space and built in shelves. LPA Sanchez P. observed all three (3) bedrooms to have linens, blankets, pillows, and working lights. Bathrooms: Bathroom #1: is located inside of Bedroom #1. Bathroom #2: is located along the hallway near the kitchen and Bedroom #1 and #2. Additionally, there are two (2) other bathrooms located in the detached clinical building. All bathrooms were inspected and found to be in good repair and working order. The hot water temperature was tested and found to be between 105-120 degrees (F). The carbon monoxide and smoke detectors were tested and found to be in working order. The facility has six (6) regulation fire extinguishers. The facility has a working telephone readily accessible. Temperatures in client rooms and common areas are maintained by a central air and heating system and the home was found to be between 68 - 85 degrees (F). Report Cont. on LIC 809-C. Pg. 3 of Overall LPA Sanchez P. observed the facility to be clean, safe, sanitary and in good repair. The front yard and outdoor spaces were clean and free of debris. Passageways, open porches, and all exits were observed to be unobstructed. Licensee ensures that individuals supervising children in the pool area are Water Safety trained. The facility operates within license conditions and limitations including capacity limitations. All posting requirements for Group Home Licensure, including the Emergency Plan, Personal Rights, and Grievance Procedures were met and posted on the wall. LPA Sanchez P. discussed the following: Children are accorded their Personal Rights. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. LPA Sanchez P. reiterated the importance of reporting and submitting Incident Reports, Law Enforcement contact, and reporting all changes within the facility to Community Care Licensing and any other appropriate agencies. The Administrator will ensure the Unusual Incident Report LIC 624, and LIC 624LE forms are utilized to document incidents. LPA Sanchez P. was provided with a copy of the Personnel Report (LIC 500) and Client Register (LIC 9020). LPA will return at a later date to review client and staff records. There are no deficiencies observed or cited at this time during this inspection. An exit interview was conducted with Brenda Reyes, Regional Operations Manager, and a copy of this report was left at the facility. Pg. 4 of 4


summary: Facility Evaluation

raw_content:
Narrative:
On November 18, 2025 at 9:20am, Licensing Program Analyst (LPA) Emelyn Sanchez P. made an unannounced visit to Ascend Healthcare 5 for the purpose of conducting a Case Management- Annual Continuation Inspection visit. LPA Sanchez P. met with Brenda Reyes, Regional Operations Manager and Jaqueline M. Waldron, Administrator. LPA Sanchez P. was granted access to the facility. The facility keeps staff and client files and documents in digital system called KIPU and Isolved. LPA reviewed the following records during the inspection: Client Records: The program currently has a total of six (6) clients. LPA Sanchez P. reviewed two (2) client records and found each record to meet licensing requirements. Staff Records: The program currently has a total of twenty-six (26) staff. LPA reviewed a total of three (3) staff records and confirmed files contained staff qualifications, current CPR/First Aid cards, required training hours, health screening, and TB test results. LPA Sanchez P. obtained the LIC 500 to verify staff to client ratio. LPA reviewed the Facility Profile and Personnel Report and confirmed that personnel have required criminal record clearance: DOJ, FBI and Child Abuse; which meet licensing requirements. LPA Sanchez P. conducted interviews with two (2) clients and a total of three (3) staff. Per California Code Regulations, TITLE 22, DIVISION 6, CHAPTERS 5 no deficiencies were cited. An exit interview was conducted, and a copy of this report was left with Brenda Reyes, Regional Operations Manager


facility_name: ASCEND HEALTHCARE 7

summary: Facility Evaluation

raw_content:
Narrative:
On April 9, 2024, Licensing Program Analyst (LPA) C. White arrived at Ascend Healthcare #7 for the purpose of conducting a Group Home Pre-licensing inspection. LPA met with Director of Operations, Jaqueline Marshall Waldron and Administrator, Brenda Reyes who granted access to the facility and provided the tour. Ascend Healthcare #7 is a therapeutic treatment program designed to accept "Private Placement's" for a length of 45 to 90 days. The facility will be licensed to provide care and supervision for six (6) children, ages 12-17 years old; ambulatory only. Currently the census is zero (0). The facility is set up as follows: This is a single-story home. There are three (3) bedrooms, five (5) bathrooms, living room, dining room, kitchen, a group room, a classroom, medication room, a clinical room, two (2) offices, laundry room, an attached garage, and outdoor/backyard area. Living room: has a sectional sofa, operational gas burning fireplace equipped with security glass, and a door leading to the patio and backyard. Dining room: Is equipped with a wooden table with eight (8) chairs. Kitchen: Is equipped with refrigerator/freezer, a gas stove with six (6) working burners, two (2) microwaves, dishwasher, and a pantry. LPA observed a covered trash can with a mechanical foot closing device. There were ample plates, cups, and eating utensils. Sharp knives will be stored in a locked drawer in the medical room. LPA observed ample non-perishable food items and snacks in pantry. The Applicant will ensure that three (3) nutritious meals and snacks will be provided to the children in care. Group Room: One group room has a mirrored wall, eight (8) chairs, an operational gas burning fireplace equipped with security glass, and wall to floor windows looking out to the backyard. Classroom: The has six (6) desks, chairs, computers, and an operational electric fireplace equipped with security screen. The room also has an attached bathroom. Medication room: was observed to have a standing locked cabinet for use to store PRN medications and separate bins for prescribed medications for individual children; multiple locked and labeled cabinets; a complete First Aid kit; a small locked refrigerator for use to store medication. Report continued on LIC 809C. (Page 1 of 3). The following was discussed with the facility Administrator: Children will be accorded personal rights. Children in care will be supported, encouraged to participate in extracurricular activities. Children in care will be able to contact the licensing agency. Children will be supervised & protected at all times. Children will be accorded dignity in personal relationships with others in the home. Children will not be restricted in telephone use except by court order. Applicant will ensure to have written authorization to obtain medical and dental care. Applicant will ensure to have personal rights forms in children's files. Applicant acknowledges abuse reporting requirements. Staff working in the facility will have DOJ/FBI criminal record clearances, and Child Abuse Index Checks. Facility will operate within license conditions & limitations including capacity limit. Facility meets posting requirements. There were no deficiencies cited at this time. LPA concluded the Pre license Inspection. An Exit interview was conducted, and a copy of this report was left at the facility with the Program Administrator. (Page 3 of 3). Clinical room: has a desk, chair, and two (2) chairs. The room has a door that opens to the backyard. Offices: are located near the classroom. Each room has two (2) chairs. Laundry room: is located near the medication room. The room is equipped with one (1) washer, one (1) dryer, and a sink. This room also has a door that opens to the garage. Attached Garage: is used to store disinfectants and extra cleaning supplies, which will be made inaccessible to children in care. Bedrooms: There are three (3) bedrooms. Bedroom #1 is equipped with two (2) twin beds; Bedroom #2 is equipped with two (2) queen size beds; Bedroom #3 is equipped with two (2) twin beds. All rooms have adequate closet and drawer space and working lights. Bathrooms: There are five (5) bathrooms. One bathroom is located in the classroom; one bathroom is located in bedroom #3; one bathroom is located next to bedroom #2; one bathroom is located in the hallway to the left of the entrance; and one bathroom is located next to the medical room. All bathrooms have a toilet, sink, and a shower. Bathrooms were found to be clean and in working order. Outdoor Area: The entire property is fenced in. Water and electric shut off valves are located in the front of the house. The gas shut off utility valve is located next to the gate up front. The front lawn has grass and trees. The backyard has a gated pool and jacuzzi that meet regulations. There is an outside seating area that contains a gas grill, a small refrigerator, a table with eight (8) chairs, and a sofa. There is an enclosed garden, a chicken coop, a shed used to store animal food and supplies, and a large, detached garage which will be used for storage. LPA observed the home to have ten (10) regulation fire extinguishers. The smoke detectors and carbon monoxide alarm were tested and found to be operating properly. There are no security bars on the windows. There are no firearms or dangerous weapons in the home. The gas shut off valve is located in the back of the house, the water shut off valve is in the front of the home, and the electric shut off panel is located in the attached garage. Facility appears to be clean, safe, sanitary, and in good repair. Passageways and porch were clean and in good repair. The front and back yard were free of debris and hazardous material. Report continued on LIC 809C. (Page 2 of 3).

met_with: Administrator - Brenda Reyes


summary: Facility Evaluation

raw_content:
Narrative:
On August 23, 2024, Licensing Program Analyst's (LPA) C. White and J. Armstrong arrived at Ascend Healthcare #7 for the purpose of conducting a Group Home Post Licensing inspection. LPA met with Administrator, Brenda Reyes who granted access to the facility and provided the tour. Ascend Healthcare #7 is a therapeutic treatment program designed to accept "Private Placement's". The facility is licensed to provide care and supervision for six (6) children, ages 12-17 years old; ambulatory only. Currently the census is five (5). The facility is set up as follows: This is a single-story home. There are three (3) bedrooms, five (5) bathrooms, living room, dining room, kitchen, a group room, a classroom, medication room, a clinical room, two (2) offices, laundry room, an attached garage, and outdoor/backyard area. Living room: a sofa, operational gas burning fireplace equipped with security glass, and a door leading to the patio and backyard. Dining room: Is equipped with a wooden table with eight (8) chairs. Kitchen: Is equipped with refrigerator/freezer, a gas stove with six (6) working burners, microwaves, dishwasher, and a pantry. LPA observed a trash can with a fitted lid. There were ample plates, cups, and eating utensils. Sharp knives are stored in a locked bin within a locked kitchen cabinet. Facility had ample non-perishable food items and snacks in pantry at the time of the visit. License ensures clients in care receive three (3) meals and snacks per day. Group Room: One group room has a mirrored wall, chairs, an operational gas burning fireplace equipped with security glass, and wall to floor windows looking out to the backyard. Classroom: The has six (6) desks, chairs, computers, and an operational electric fireplace equipped with security screen. The room also has an attached bathroom. Medication room: was observed to have a standing locked cabinet storing PRN medications with separate bins for prescribed medications for individual children; locked cabinets; complete First Aid supplies; and a locked refrigerator to store medication. Clinical room: has a desk, computer, and two (2) chairs. The room has a door that opens to the backyard. Report continued on LIC 809C Offices: are located near the classroom. Each room has two (2) chairs. Laundry room: is located near the medication room. The room is equipped with one (1) washer, one (1) dryer, a sink and has multiple cabinets which store disinfectants and extra cleaning supplies, all made inaccessible to clients in care. This room also has a door that opens to the garage. Attached Garage: has two (2) additional refrigerators and one (1) standalone freezer. Bedrooms: There are three (3) bedrooms. Bedroom #1 is equipped with two (2) twin beds; Bedroom #2 is equipped with two (2) queen size beds; Bedroom #3 is equipped with two (2) twin beds. All rooms have adequate closet and drawer space and working lights. Bathrooms: There are five (5) bathrooms. One bathroom is located in the classroom; one bathroom is located in bedroom #3; one bathroom is located next to bedroom #2; one bathroom is located in the hallway to the left of the entrance; and one bathroom is located next to the medical room. All bathrooms have a toilet, sink, and a shower. Bathrooms were found to be clean and in working order. Outdoor Area: The property is fenced in. The backyard has a gated pool and jacuzzi that meet regulations. There is an outside seating area that contains a gas grill, a small refrigerator, a table with eight (8) chairs, and a sofa. There is an enclosed garden, a chicken coop, a shed used to store animal food and supplies, and a large, detached garage which is used for storage. LPA observed the home to have ten (10) regulation fire extinguishers. The smoke detectors and carbon monoxide alarm were tested and found to be operating properly. There are no security bars on the windows. There are no firearms or dangerous weapons in the home. Facility appears to be clean, safe, sanitary, and in good repair. Passageways and porch were clean and in good repair. The front and back yard were free of debris and hazardous material. LPA reminded the Administrator to ensure Children in care are accorded personal rights. Children are to be supported, encouraged to participate in extracurricular activities. Children are allowed to contact the licensing agency. Children are to be supervised and protected at all times. Children are to be accorded dignity in personal relationships with others in the home. Children will not be restricted in telephone use except by court order. Staff working in the facility have DOJ/FBI criminal record clearances, and Child Abuse Index Checks. Facility meets posting requirements. There were no deficiencies cited at this time. LPA concluded the Post License Inspection. An Exit interview was conducted, and a copy of this report was emailed to the Administrator.

met_with: Brenda Reyes - Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On May 28, 2025, Licensing Program Analyst (LPA) C. White arrived at Ascend Healthcare #7 for the purpose of conducting an Annual/Required inspection. LPA met with Facility Manager, Barbara Gonzalez who granted access to the facility and provided the tour. Ascend Healthcare #7 is a therapeutic treatment program designed to accept "Private Placement's" for a length of 45 to 90 days. The facility is licensed to provide care and supervision for six (6) children, age 12-17 years old; ambulatory only. Currently the census is six (6). The facility is set up as follows: This is a single-story home. There are three (3) bedrooms, five (5) bathrooms, living room, dining room, kitchen, a group room, a classroom, medication room, a clinical room, two (2) offices, laundry room, an attached garage, and outdoor/backyard area. Living room: has a sofa, operational gas burning fireplace equipped with security glass, and glass doors leading to the patio and backyard. Dining room: Is equipped with a wooden table with eight (8) chairs. Kitchen: Is equipped with refrigerator/freezer, a gas stove with six (6) working burners, two (2) microwaves, dishwasher, and a pantry. LPA observed ample plates, cups, and eating utensils. Sharp knives are kept in a locked box in a locked cabinet next to the stove. The facility had ample non-perishable and perishable food items and snacks in the pantry. The Licensee ensures clients are provided with three (3) nutritious meals and snacks daily. Group Room: Is equipped with eight (8) chairs, has an operational gas burning fireplace equipped with security glass, mirrored walls, exercise mats, and glass doors leading to the backyard. Report continued on LIC 809C (Page 1 of 3) Classroom: Is located near the client bedrooms and is equipped with a wooden table and six (6) chairs, six (6) computer desks, chairs, computers, and an operational electric fireplace equipped with security screen. The room also has an attached bathroom, which remains locked at all times, and contains a storage closet for classroom equipment. There is also a patio door leading to the backyard. Medication room: LPA observed multiple locked and labeled cabinets; a complete First Aid kit; a small, locked refrigerator for use to store medication; a standing locked cabinet for use to store PRN medications and separate bins for prescribed medications for individual clients; a built in desk, chair, and a computer. Clinical room: has a desk, chair, and two (2) chairs. The room has a door that opens to the backyard. Offices: Both are located near the classroom. One room has a desk, two (2) chairs, and storage cubies. One room has a desk, computer, and a chair. Laundry room: is located near the medication room. The room is equipped with one (1) washer, one (1) dryer, and a sink. The room has multiple cabinets, which remain locked, and are used to store laundry detergent and other cleaning supplies. The room has a door that opens to the garage. Attached Garage: is used to store disinfectants, extra cleaning supplies, and has two (2) freezers that contain surplus food supplies. The garage is made inaccessible to children in care. Bedrooms: There are three (3) bedrooms. Bedroom #1 is equipped with two (2) twin beds; Bedroom #2 is equipped with two (2) queen size beds; Bedroom #3 is equipped with two (2) twin beds and has an attached bathroom. All rooms have adequate closet and drawer space, windows, and working lights. Bathrooms: There are five (5) bathrooms. One bathroom is located in the classroom; one bathroom is located in bedroom #3; one bathroom is located next to bedroom #2; one bathroom is located in the hallway to the left of the entrance; and one bathroom is located next to the medical room. All bathrooms have a toilet, sink, and a shower. Bathrooms were found to be clean and in working order. Outdoor Area: The entire property is fenced in. The front lawn has grass and trees. The backyard has a pool and a jacuzzi enclosed with a gate that meet regulations. There is an outside seating area that contains a gas grill, a small refrigerator, a table with eight (8) chairs, and a sofa. Report continued on LIC 809C (Page 2 of 3) There is an enclosed garden, an equine farm with goats, sheep, horses, and a pig; a pig pin, a shed used to store animal food and supplies, and a large, detached garage that is used for storage. LPA observed the home to have multiple regulation fire extinguishers. The smoke detectors and carbon monoxide alarm were tested and found to be operating properly. There are no security bars on the windows. There are no firearms or dangerous weapons in the home. The gas shut off valve is located in the back of the house, the water shut off valve is in the front of the home, and the electric shut off panel is located in the attached garage. Facility appears to be clean, safe, sanitary, and in good repair. Passageways and porch were clean and in good repair. The front and back yard were free of debris and hazardous material. LPA reminded the Facility Manager to ensure clients in care are accorded personal rights. Clients are to be supported, encouraged to participate in extracurricular activities. Clients are allowed to contact the licensing agency. Clients are to be supervised and protected at all times. Clients are to be accorded dignity in personal relationships with others in the home. Clients will not be restricted in telephone use except by court order. Facility meets posting requirements. LPA reiterated the importance of reporting and submitting Incident Reports, Law Enforcement contact, and reporting all changes within the facility to Community Care Licensing and any other appropriate agencies. The Administrator will ensure the Unusual Incident Report LIC 624, and LIC 624LE forms are utilized to document incidents. Clients Records are electronically stored in the facilities online Portal with Kipuworks.com Staff Records are electronically stored in the ISolved system. Facility Manager provided LPA with a copy of the Personnel Report (LIC 500) and a current Client Roster (LIC 9020). LPA will return at a later date to review client and staff records. There are no deficiencies observed or cited at this during this inspection. Exit interview was conducted with the Facility Manager, and a copy of this report was left at the facility. (Page 3 of 3)

met_with: Barbara Gonzalez - Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On June 5, 2025, Licensing Program Analyst (LPA) C. White, made an unannounced visit to Ascend Healthcare 7, for the purpose of conducting a Case Management Annual Continuation Inspection. LPA met with Administrator, Brenda Reyes and was granted access to the facility and provided the requested information. The facility keeps clients records electronically stored in an online system call KIPUERM and staff Records are electronically stored in the ISolved system. LPA reviewed the following records during the inspection: Client Records: The program currently has a total of six (6) clients. LPA reviewed a total of three (3) client records and found each record to meet required regulations. Staff Records: The program currently has a total of twenty-five (25). LPA reviewed a total of five (5) staff records and confirmed files contained staff qualifications, current CPR/First Aid cards, health screening, and TB test results. LPA obtained the LIC 500 to verify Staff to Client ratio. LPA reviewed the Facility Profile and Personnel Report and confirmed that personnel have required criminal record clearance: DOJ, FBI and Child Abuse; which meet qualification. This inspection included an overview of required Core Services and Supports and based upon inspection of facility records and interviews of staff and clients. Licensee is meeting all requirements. PER California Code Regulations, TITLE 22, DIVISION 6, CHAPTERS 5, General Licensing Regulations the following deficiency was observed and cited at the time of this inspection. (See LIC 809D). A copy of this report was emailed to the Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On September 11, 2025, Licensing Program Analyst (LPA), Emelyn Sanchez P. made an unannounced visit to Ascend Healthcare 7 for the purpose of conducting a Follow-up Case Management- Incident visit regarding a medication error. LPA Sanchez P. met with Regional Operations Manager, Brenda Reyes to discuss the incident. The special incident report was reported to the Department on 09/04/2025. The incident occurred on 09/02/2025. The incident stated a client was given the PM dosage of Psychotropic medication instead of the AM dosage of the Psychotropic medication. Based on the information provided, and interviews conducted, it was confirmed that a medication error occurred on 09/02/2025. The Department has concluded, based on the preponderance of the evidence obtained, that staff failed to administer the client's medication as prescribed. LPA informed Regional Operations Manager, Brenda Reyes that the facility would be cited. The following deficiency is being cited for violating California Code of Regulations Title 22, Division Regulation 80075(b)(5)(B) Health Related Services. (see page D). Exit interview was completed and copy of the report and appeal rights were discussed and provided to Regional Operations Manager, Brenda Reyes.

met_with: Regional Operations Manager- Brenda Reyes


summary: Facility Evaluation

raw_content:
Narrative:
On May 5, 2026 at 9:30am Licensing Program Analyst (LPA) Emelyn Sanchez P. made an unannounced visit to Ascend Healthcare 7 for the purpose of conducting a Annual/Required inspection visit. LPA Sanchez P. met with Brenda Reyes, Regional Operations Manager who granted access to the facility. LPA Sanchez P. toured the interior and exterior of the facility. The facility is licensed to provide care and supervision services for up to six (6) male and female children, ages 11-17 years old, ambulatory only. There is a swimming pool on the premises which meets licensing regulations. The census at the time of the inspection was six (6). The facility is set up as follows: This is a single-story home. There are three (3) bedrooms, four and a half (4 1/2) bathrooms, living room, dining room, kitchen, a group room, a classroom, medication room, five (5) offices, laundry room, an attached garage, outdoor/backyard area with a farm. Living room: Is equipped with a sectional sofa, two chairs, mounted TV, operational gas burning fireplace equipped with security glass, and glass doors leading to the patio and backyard. Dining room: Is equipped with a wooden table with seven (7) chairs. Kitchen: Is equipped with refrigerator/freezer, a gas stove with six (6) working burners, two (2) microwaves, dishwasher, and a pantry. LPA Sanchez P. observed ample plates, cups, and eating utensils. Sharp knives are kept in a locked box in a locked cabinet next to the stove. The facility had ample non-perishable and perishable food items and snacks in the pantry. The Licensee ensures clients are provided with three (3) nutritious meals and snacks daily. Report Cont. on LIC 812-C. Pg. 1 of Group Room: Is equipped with eight (8) chairs, has an operational gas burning fireplace equipped with security glass, mirrored walls, exercise mats, and glass doors leading to the backyard. Classroom: Is located near the client bedrooms and is equipped with a wooden table and six (6) chairs, six (6) desks, chairs, computers, and an operational electric fireplace equipped with security screen. The room also has an attached bathroom, which remains locked at all times, and contains a storage closet for classroom equipment. There is also a patio door leading to the backyard. Medication room: Is equipped with multiple locked and labeled cabinets; a complete First Aid kit; a small, locked refrigerator for use to store medication; a standing locked cabinet for use to store PRN medications and separate bins for prescribed medications for individual clients; a built in desk, chair, and a computer. Laundry room: Is located near the medication room. The room is equipped with one (1) washer, one (1) dryer, and a sink. The room has multiple cabinets, which remain locked, and are used to store laundry detergent and other cleaning supplies. The room has a door that opens to the garage. Attached Garage: Is equipped with two (2) refrigerators and one (1) freezer that contain extra food supplies. The garage is made inaccessible to children in care. Bedrooms: There are three (3) bedrooms. Bedroom #1 is equipped with two (2) twin beds, two (2) night stands and a closet. Bedroom #2 is equipped with two (2) full size beds, two (2) night stands, two dressers and a closet. Bedroom #3 is equipped with two (2) twin beds, (2) night stands, dresser, and has an attached full bathroom. All rooms have adequate closet and drawer space, windows, and working lights. Bathrooms: There are four and a half (4 1/2) bathrooms. One bathroom is located in the classroom; one bathroom is located in bedroom #3; one bathroom is located next to bedroom #2; the half bathroom is located in the hallway to the left of the entrance; and one bathroom is located next to the medical room. Bathrooms were found to be clean and in working order. Report Cont. on LIC 812-C. Pg. 2 of Offices: There are five (5) office rooms. First office is located to the right once entering the facility. It is equipped at a desk, two (2) chairs, and a book case. Second office is located to the right leading into the classroom. It is equipped with a desk and chair. Third office is located to the left leading into the classroom. It is equipped with a desk and chair. Fourth office is a converted office space located inside the garage. It is equipped with a desk, chair, bookshelves, coffee table and sofa. The fifth office is a shed located outside. It is equipped with a desk, chair and sofa. Outdoor Area: The entire property is fenced in. The front lawn has grass and trees. The backyard has a pool and a jacuzzi enclosed with a gate that meet licensing regulations. There is an outside seating area that contains a gas grill, a table with eight (8) chairs, and a sofa. There is an enclosed garden, an equine farm with goats, horses, and a pig; a pig pin, a shed used to store animal food and supplies, and a large detached garage that is used as an art studio. Transportation: The facility uses a KIA Carnival to transport children in care. LPA Sanchez P. inspected the vehicle and found it to be in good repair. LPA Sanchez P. observed the vehicle to have current registration and valid insurance. The carbon monoxide and smoke detectors were tested and found to be in working order. The facility has six (6) regulation fire extinguishers. The facility has a working telephone readily accessible. Temperatures in client rooms and common areas are maintained by a central air and heating system and the home was found to be between 68 - 85 degrees (F). Overall LPA Sanchez P. observed the home to be clean, safe, sanitary, and in good repair. The front yard and outdoor spaces were clean and free of debris. The home has a linen closet located in the hallway by the bedrooms which stores additional towels and sheets. Disinfectant and cleaning solutions are locked in the laundry room and made inaccessible to the clients. There are no firearms or dangerous weapons located in the home. Licensee ensures that individuals supervising children in the pool area are Water Safety trained. The facility operates within license conditions and limitations including capacity limitations. All posting requirements for Group Home Licensure, including the Emergency Plan, Personal Rights, and Grievance Procedures were met and posted on the wall. Report Cont. on LIC 812-C. Pg. 3 of LPA Sanchez P. discussed the following: Children are accorded their Personal Rights. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. LPA Sanchez P. reiterated the importance of reporting and submitting Incident Reports, Law Enforcement contact, and reporting all changes within the facility to Community Care Licensing and any other appropriate agencies. The Licensee will ensure the Unusual Incident Report LIC 624, and LIC 624LE forms are utilized to document incidents. LPA Sanchez P. was provided with a copy of the Personnel Report (LIC 500) and Client Register (LIC 9020). The facility keeps client files and documents in digital system called KIPU. The facility keeps staff files and documents in digital system called Isolved. LPA Sanchez P. reviewed the following records during the inspection: Client Records: The program currently has a total of six (6) clients. LPA Sanchez P. reviewed three (3) client records and found each record to meet licensing requirements. LPA Sanchez P. will return at a later date to review staff files and to conduct interviews with staff and clients. There are no deficiencies observed or cited at this time during this inspection. An exit interview was conducted with Brenda Reyes, Regional Operations Manager, and a copy of this report was left at the facility. Pg. 4 of 4


facility_name: ASCEND HEALTHCARE 8

summary: Facility Evaluation

raw_content:
Narrative:
On April 24, 2025 at 10: AM, Licensing Program Analyst (LPA) Charmetha White made an announced visit to Ascend Healthcare #8 for the purpose of completing the Group Home Pre-Licensing Inspection. LPA met with Administrator, Jaqueline Marshall Waldron, and Facility Manager, Brenda Reyes and was granted access to the facility. This facility will be licensed to provide care and supervision for six (6) children ages 12-17 years old, ambulatory only. Current census is zero (0). The facility is set up as follows: This is a two-story home located in a residential neighborhood. There are four (4) bedrooms, five and one half (5 ½) bathrooms, living room, dining room, kitchen, group room, lounge room, medication office, four (4) office rooms, classroom area, laundry area, an attached garage, and backyard area. Living room: Is equipped with a sectional sofa, two (2) chairs, a mounted TV, and an operational gas burning fireplace equipped a retractable glass security door. The room has windows, working lights and opens to the dining room. Dining room: Is equipped with a wooden table with eight (8) chairs, and a glass chandelier. The room has windows, working lights, and opens to the kitchen. Kitchen: Is equipped with a double door refrigerator/freezer, double ovens, a kitchen island with a five (5) burner gas cooktop (all operational at the time of the inspection), a microwave, dishwasher, and trash compactor. LPA observed a wooden table with two (2) benches, a covered trash can, two (2) locked pantries, plenty of cabinet space, ample plates, cups, and eating utensils. Sharp knives are stored in a locked cabinet located next to the sink and made inaccessible. A weekly menu was posted, and food will be prepared by a private chef and delivered to the home. The applicant will ensure that three (3) nutritious meals and snacks will be provided to the clients in care. Group Room: is equipped with eight (8) chairs, window, and working lights. The room has patio doors which lead to the side of the house containing the equine therapy farm. Report Continued on LIC 809C (Page 1 of 3) Lounge Room: is equipped with a couch, two (2) chairs, a small wooden coffee table, an operational gas burning fireplace equipped with an iron screen, windows, working lights, and a patio door leading to the backyard. This room will be used for visitation. Medication Office: is located off the kitchen next to a staircase leading the second floor. The room is equipped with multiple built in locked cabinets, which store PRN medications, first aid supplies, separate bins for prescribed medications for individual clients, and a locked bock for additional sharps. The room also contains a small combination lock refrigerator to store medications, a sink, windows, working lights, and a door that leads to the backyard. Offices: One office is located to the left of the lounge room and will be used for therapy. The is equipped with a desk and chair, a sofa, two (2) additional chairs, a small wooden coffee table, and a bookshelf. The room opens to the Second office which will be used for therapy. This room is equipped with a mounted TV. The Third office is attached to the group room. This office is equipped with a sofa, two (2) chairs, a desk and chair, a mounted TV, a operational gas burning fireplace equipped a retractable glass security door, windows, working lights, and built in shelves. The Forth office is located on the second floor to next to the classroom area and will be used for staff. The room is equipped a desk, chair, built in cabinet space, and contains the WiFi and cable connections. Classroom Area: This area is located on the second and is equipped with six (6) computers, six (6) wooden desk and chairs, a wooden table with five (5) chairs, a pool table, and multiple windows. There is a locked storage closet at the top of the stairs which will be used to store classroom supplies. Additionally, this closet has an unlocked crawl space door leading the homes insulation. Laundry area: is located inside the attached garage and has a washer/dryer. LPA observed locked cabinets above the appliances which contain additional disinfectants and laundry supplies. Attached Garage: This is a 3-car garage which will be used for storage. LPA observed an additional refrigerator, freezer, mattresses, and boxes in this area. Backyard area: contains a ½ court basketball area, a hooded grill, a fenced and gated pool/jacuzzi that meets regulations, a enclosed trampoline, a small garden, a wooden table with two (2) attached benches, and a working firepit. On the side of the home is small equine therapy farm that has 4 goats, chickens, and a small barn. The barn contains a chicken coop, built in storage cabinets that store animal supplies, two (2) desk, and two (2) chairs. Bedroom #1: is equipped with two (2) twin size beds, built in storage shelves with four (4) drawers, and two (2) nightstands. Bedroom #2: is equipped with two (2) full size beds, built in storage shelves with four (4) drawers. The room also has a walk-in closet that will remain locked at all times and not be used due to access to a crawl space that lead to the homes insulation. Bedroom #3: is equipped with one (1) full size bed, a dresser, and two (2) closets with built in shelves. Report Continued on LIC 809C (Page 2 of 3) Bedroom #4: is equipped with one (1) full size bed, a dresser, and a walk-in closet that has separate locked door leading the hallway. All bedrooms were all observed to have mattresses, bed linen, blankets, pillows, windows, and working lights. Bathrooms: Three bathrooms are located on the first floor. Two bathrooms are located on the second floor. The bathrooms contain a toilet, sink, and shower. There is also a ½ bathroom located near the front entrance that contains a toilet and a sink. All bathrooms were checked and found to be in working order. The hot water was tested, and the temperature was found to be between 105 -120 (F). LPA observed the home to have eight (8) regulation fire extinguishers. The smoke detectors and carbon monoxide alarm were tested and found to be operating properly. The First Aid kit was checked and found to be complete with scissors, tweezers, thermometer, and gauzes, antiseptic and First Aid Manual Guide. Extra linens, hygiene supplies, and disinfectants were stored in locked hallway closets. There are no security bars on the bedroom windows. There are no firearms or dangerous weapons in the home.Facility appears to be clean, safe, sanitary, and in good repair. Passageways and porch were clean and in good repair. The front and back yard were free of debris and hazardous material. Applicant showed LPA were the gas shut-off valves, the electrical panel, and water shut off valves were located. The following was discussed with the facility Administrator: Children will be accorded personal rights. Children in care will be supported, encouraged to participate in extracurricular activities. Children in care will be able to contact the licensing agency. Children will be supervised & protected at all times. Children will be accorded dignity in personal relationships with others in the home. Children will not be restricted in telephone use except by court order. Applicant will provide and ensure three nutritious meals, snacks, and special diets. Applicant will ensure to have written authorization to obtain medical and dental care. Applicant will ensure to have personal rights forms in children's files. Applicant acknowledges abuse reporting requirements. Staff working in the facility will have DOJ/FBI criminal record clearances, and Child Abuse Index Checks. Facility will operate within license conditions & limitations including capacity limit. Facility meets posting requirements, including COVID-19 best practices signs and emergency telephone numbers are in prominent locations. The facility will use a Honda, Odyssey to transport youth to appointments and offsite extra curriculum recreational activities. LPA inspected the vehicle and found horn, lights, and all seatbelts in working order. The vehicle is equipped with a complete First Aid Kit, and Roadside emergency kit. LPA observed the vehicle to have valid car insurance through Ace Property & Casualty Insurance Company. LPA concluded the Pre license Inspection. An Exit interview was conducted, and a copy of this report was left at the facility with the Program Administrator. (Page 3 of 3)

met_with: Jaqueline Marshall Waldron - Administrator, and Brenda Reyes - Facility Manager