summary: Facility Evaluation

raw_content:
Narrative:
On the above date, An unannounced annual inspection was conducted by Licensing Program Analyst (LPA) Lidia Tinoco. LPA traveled to the Creative Alternatives main office in Merced, CA. LPA met with Program Director, Brandi Boehme and Assistant Program Director, Dawn Lee for the purpose of reviewing staff files. LPA Reviewed Staff Files. 2 of the staff files reviewed have Exemptions, verified paperwork. No deficiencies cited on today's visit. A copy of this report was left with Brandi Boehme at the conclusion of inspection.

met_with: Brandi Boehme, Dawn Lee


state: CA

facility_name: MERCED RANCH

summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by Licensing Program Analyst (LPA) Lidia Tinoco traveled to the Merced Ranch STRTP in Merced, CA. LPA met with Administrator, Jeanne Johnson and inspected the facility. LPA Reviewed a total of Client files. LPA discovered that signatures from the authorized representatives were missing in 4 files in the needs and services plans. The facility was able to provide documented attempts to contact county social workers for 3 of the 4 files. One of the files did not have representative signatures for 6 months. LPA will conduct Staff and Client interviews at a later date. Facility was cited for the Interim Licensing Standards Version 4, Section 87068.2(h) Needs and Services Plan. A copy of this report was left with Jeanne Johnson at the conclusion of inspection.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Jeanne Johnson


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by Licensing Program Analysts (LPA's) Lidia Tinoco and Vanessa Galvan traveled to the Merced Ranch STRTP in Merced, CA. LPA's met with Administrator, Jeanne Johnson. LPA's conducted Staff and Client interviews. LPA Tinoco cleared the Deficiency issued on 11/05/2021. No deficiencies observed or cited on today's visit, a copy of this report was left to Jeanne Johnson at conclusion of inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analysts (LPAs) Lidia Tinoco and Reyna Martinez Traveled to the Merced Rach Facility for the purpose of conducting a Case Management and met with Administrator Aaron Holloway. LPAs addressed the increased incident reports coming from this facility. Administrator explained the merge from Bear Creek and other client specific reasons for increased reports. LPAs Addressed the incident that occurred on August 17, 2022. Per Administrator, repairs have been made to the facility that were observed including the knife drawer that was broken. The facility currently keeps the knives locked in the office and will continue to keep them locked in the office until a count system is put in place to account for checked out knives. Administrator shared with LPAs that a facility meeting will be held on August 31, 2022 where supervision and communication will be addressed with staff. LPAs conducted a walk through of the facility and observed the mentioned repairs. No deficiencies were cited on todays visit a copy of this report was provided at the conclusion of the inspection.

met_with: Aaron Holloway


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by Licensing Program Analysts (LPAs), Lidia Tinoco and Reyna Martinez traveled to the Merced Ranch STRTP in Merced, CA. LPA met with Facility Administrator Aaron Holloway. A physical plant inspection was completed and included the following checks. Facility grounds are clean and free of debris. Adequate indoor and outdoor activity space and materials observed. The Facility has a pool with fencing. The facility is maintained at 68 degrees. All facility smoke detectors and carbon monoxide detectors are in appropriate working order. Facility maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted. 2 clients require medications currently, facility has the ability to keep Medications locked and centrally stored. Individual beds were observed with appropriate clean linens and are in good repair. Licensee has obtained Mental Health Certification Including the following: Mental Health Program Approval visit was conducted August 25, 2022 pending response. Licensee has obtained National Accreditation through CARF valid through September 30, 2023. The facility has a county contract valid through June 30, 2025. Medical Certification Visit conducted on April 26, 2022. No firearms or weapons are allowed in the facility. Facility appears to be meeting the terms and conditions of their license. LPA reviewed 5 client files. One Type A Deficiency was cited on today's visit for CCR 80076(a)(1) Food Service. A copy of this report was left at the conclusion of the inspection.

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco traveled to the Merced Ranch STRTP for the purpose of concluding the Annual Inspection. LPA reviewed 5 staff files and conducted client interviews. No Deficiencies were observed or cited on today's visit. A copy of this report was provided at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco met with Program Director, Brandi Boehme at the Creative Alternatives Main office in Merced. LPA Delivered PPE - N Masks and Gloves. LPA also obtained pertinent documents related to a complaint investigation. No deficiencies were observed or cited. A Copy of this report was provided at the conclusion of the inspection.

met_with: Brandi Boehme


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco conducted a Case Management regarding an incident report received 04/17/23 and met with Brandi Boehme. On April 15, 2023 an incident involving a restraint of a client occurred. LPA addressed the incident with Program Director Brandi. No Deficiencies were cited on today's visit. A copy of this report was provided.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian on July 24, 2023 at 9:30AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPA met with Aaron Holloway, Administrator and inspected the facility inside and out. LPA reviewed 6 child's records and 2 staff personnel files on site at the facility. LPA reviewed 6 child's psychotropic medications and medication records. LPA interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA interviewed four children on site currently on psychotropic medication. Two children refused to be interviewed. LPA provided a copy of the licensing report to Administrator, Aaron Holloway. No deficiencies are being cited at this time. LPA conducted exit interview with Aaron Holloway, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, LPA (Licensing Program Analyst) Lisa Slusher conducted a collateral inspection for the purpose of conducting a client Interview. (1) One interview conducted. There are no deficiencies to be cited at this time

met_with: Eddie Cortez


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco met with Administrator, Aaron Holloway for the purpose of conducting an Annual/Random inspection for the Merced Ranch STRTP. Administrator, Aaron Holloway is present at the facility a minimum of 20 hours a week. The facility employs Social Worker, 2 facility managers and 10 direct care staff. Licensee has obtained Mental Health Certification Including the following: Mental Health Program Approval valid through September 24,2024. Agency had a Mental Health Program Approval inspection the week of September 16-20, 2024 and are pending results. Licensee has obtained National Accreditation through CARF. The Accreditation is valid through September 30, 2026. 5 records of staff were reviewed. (See LIC811 confidential names list). This annual will be completed at a later date. No deficiencies were observed or cited on today's date. A copy of this report was provided at the conclusion of the inspection to Administrator, Aaron Holloway.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco met with Facility Supervisor, Jeanne Johnson for the purpose of continuing the Annual Inspection for the Merced Ranch STRTP. Centrally stored medications are maintained in a locked cabinet. Sharps and Toxic chemicals are kept locked. The facility has a written emergency disaster plan. All facility smoke detectors appear to be in appropriate working order, the fire extinguisher is properly charged. Individual beds were observed with appropriate clean linens and are in good repair. There is at least one-week supply of nonperishable and a two-day supply of perishable foods. Facility has a pool which is appropriately fenced and secured. No firearms or weapons are allowed in the facility. 4 records of clients were reviewed. (See LIC811 confidential names list) A Technical Violation was issued and discussed. Staff and client interviews are still required to be conducted to complete this inspection, interviews will be conducted at a later date. A copy of this report was provided at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at Merced Ranch STRTP for the purpose of conducting an unannounced Case Management inspection and met with Facility Manager, Jeanne Johnson and Administrator, Aaron Holloway. The purpose of the inspection was to discuss an incident report. The incident report dated March 30, 2025, involving C1, C2, S1, S2, S3 and S4 (See LIC Confidential Names List). LPA addressed the language chosen on the report and also restraints. LPA conducted confidential interviews. No deficiencies were cited on this date. An exit interview was conducted, and a copy of this report was provided at the conclusion of the inspection.

met_with: Jeanne Johnson, Aaron Holloway


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at Merced Ranch STRTP for the purpose of conducting an unannounced Case Management inspection and met with Facility Manager, Jeanne Johnson and Administrator, Aaron Holloway. The purpose of the inspection was to discuss the fire inspection conducted on February 26, 2025. A copy of this report was provided at the conclusion of the inspection.

met_with: Aaron Holloway, Jeanne Johnson


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Briana Placencia on April 10, 2025 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPA met with Aaron Holloway, Administrator and inspected the facility inside and out. LPA reviewed 4 child records and 2 staff personnel files on site at the facility. LPA reviewed 4 child psychotropic medications and medication records. LPA interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA was unable to conduct any interviews as the children currently on psychotropic medication are at school, they will be interviewed at a later time. LPA provided a copy of this licensing report to Aaron Holloway, Administrator. No deficiencies are being cited at this time. LPA conducted exit interview with Aaron Holloway, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On December 18, 2025, Licensing Program Analysts (LPAs), Briana Placencia and Danny Macias arrived at Merced Ranch STRTP for the purpose of conducting an unannounced Case Management Inspection and met with Facility Supervisor, Jeanne Johnson. The purpose of the inspection was to discuss concerns with buildings and grounds as a walk through was completed. During the facility walk through LPAs observed several windows to be without window screens, hot water temperature was taken and the water read 142. F. The Department determined this to be an immediate risk to health and safety at this time, therefore the STRTP is being cited on the attached LIC809-D under CCR. The Department is also issuing two Technical Violations for the facility fence and latch, as well as a sink in the clients restroom that is leaking. A review of the Licensing Information System on this date indicates that all facility staff are associated to the STRTP and had DOJ, FBI, and child abuse index check clearances. A copy of this report and appeal rights was provided to Jeanne Johnson at the conclusion of the inspection.

met_with: Facility Supervisor, Jeanne Johnson


summary: Facility Evaluation

raw_content:
Narrative:
On December 15, 2021, an unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian at 11:00AM. During the inspection, LPA met with Jeanne Johnson, Administrator and inspected the facility inside and out. LPA reviewed seven children's records and reviewed two staff personnel records for the facility at 11:30AM. A medication count was conducted at 12:30PM. LPA interviewed two staff at 1:00PM. LPA interviewed two children. The remainder of the children were not interviewed as they were at school and will be interviewed at a later date. LPA conducted exit interview with Jeanne Johnson, Administrator at 2:00PM. LPA provided the summary report upon completion.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco conducted an unannounced Case Management visit to the Merced Ranch STRTP and met with Administrator, Aaron Holloway to discuss a deficiency discovered during confidential interviews. LPA Tinoco discussed with Aaron Holloway inappropriate staff communication with clients. Aaron informed LPA Tinoco that the staff involved was already spoken to and understands their mistake. Facility was cited for 87072(c)(11) Personal Rights. Type A. A copy of this report was provided along with appeal rights.


summary: Facility Evaluation

raw_content:
Narrative:
On May 31, Licensing Program Analyst (LPA), Lidia Tinoco traveled to the Merced Ranch STRTP for the purpose of conducting a Case Management with deficiencies regarding administration of psychotropic medication. On 5/22/23, LPA Tinoco received two incident reports dated 5/21/23 indicating that staff made errors administrating medications of two youth. Facility Administrator has scheduled a staff re-training to address the errors, the training is scheduled for June 7, 2023. Medication errors were also addressed with staff at the all staff meeting on 5/31/23. Facility was cited for the Interim Licensing Standards (ILS) Section 87075(c) Health Related Services. A copy of this report was provided at the conclusion of the inspection.


summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13On February 4, 2026, Licensing Program Analyst (LPA) Danny Macias traveled to Merced Ranch Short Term Residential Therapeutic Program (STRTP) located in Merced, CA to conduct an unannounced inspection and met with Facility Administrator Aaron Holloway. The purpose of the inspection was to deliver findings for the above complaint allegations. During the investigation, LPA conducted confidential interviews, records review and reviewed supporting documents provided by the facility. Based on confidential interviews and records reviewed, the department has made the following determination. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies or citations issued. A review of the Licensing Information System on this date indicates that all facility staff are associated to the STRTP and had DOJ, FBI, and child abuse index check clearances. An exit interview was conducted and a copy of this report was left with Aaron Holloway. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Danny Macias LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

report_type: Complaint Investigation

complaint_status: unsubstantiated


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at the Merced Ranch STRTP and met with Administrator, Aaron Holloway for the purpose of conducting a Case Management inspection. LPA Tinoco received an incident report for an incident that occurred on 3/3/26. LPA Tinoco and Administrator, Aaron discussed the following topics: Runaway Plan - LPA Tinoco went over the runaway plan with the Administrator. Restraints - Administrator provided further explanation for the conducted restraint. LPA Tinoco was provided a copy of the needs and services plan requested. Based on the information provided, LPA Tinoco is issuing a Technical Violation for 87095.24(e)(1) Runaway Plan on the attached LIC9102. This report was discussed and signed at the time of the visit. A copy of this report was provided at the conclusion of the inspection.


facility_name: MICHIGAN HOUSE

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Daiquiri Boyd conducted a follow-up complaint inspection with the Short Term Residential Theraputic Program (STRTP) and met with Charles Smith. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the course of the investigation, LPA Boyd conducted interviews with client's and staff. The interviews revealed that there is no eveidence as to whether the allegations listed above happened or didn't happen. Although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove the above allegation; therefore, the allegation is unsubstantiated. LPA provided a copy of the report to the STRTP. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Daiquiri Boyd LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

met_with: Charles Smith


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Daiquiri Boyd conducted a follow-up complaint inspection with the Short Term Residential Theraputic Program (STRTP) and met with Charles Smith. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the course of the investigation, LPA Boyd and LPM Juanita Arroyo conducted interviews with clients, and staff and reviewed facility files and incident reports. The interviews revealed that there is no consistent consensus as to whether the allegations listed above happened or didn't happen. Although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove the above allegation; therefore, the allegation is unsubstantiated. LPA provided a copy of the report to the STRTP. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Daiquiri Boyd LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Daiquiri Boyd conducted a follow-up complaint inspection with the Short Term Residential Theraputic Program (STRTP) and met with Charles Smith. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the course of the investigation, LPA Boyd and LPM Juanita Arroyo conducted interviews with clients, staff, and law enforcement, and reviewed incident reports. The interviews and document review revealed that there is no consistent consensus as to whether law enforcement was contacted unnecessarily. Although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove the above allegation; therefore, the allegation is unsubstantiated. LPA provided a copy of the report to the STRTP. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Daiquiri Boyd LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Daiquiri Boyd conducted a follow-up complaint inspection to the Short Term Residential Therapeutic Program (STRTP) and met with Charles Smith. The purpose of the inspection was to deliver the findings for the above complaint allegation regarding the staff not preventing minors from smoking illegal substances while in care. During the course of the investigation, Community Care Licensing (CCL) conducted interviews with clients, staff, and school personnel. The information obtained during the interviews, indicated that the minors were permitted to smoke with a vape pen. Type A: This poses an immediate health and safety risk to clients in care. Based on the LPA's observations, interviews, and the records review conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be substantiated. A copy of the report and Appeal Rights was provided to the STRTP. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Daiquiri Boyd LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, E SHAW AVE FACILITY NAME: MICHIGAN HOUSEFACILITY NUMBER: 100406164

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

complaint_status: SUBSTANTIATED


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Reyna Martinez conducted a complaint inspection and met with Charles Smith. The purpose of the inspection was to deliver the findings for the above complaint allegation. The Department has investigated the complaint alleging facility staff are not appropriately addressing physical altercations between minors in care. LPA conducted interviews and obtained documentation.There were inconsistencies in the confidential interviews. Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violations did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Reyna Martinez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analysts (LPAs) Sonia Sanchez and Miriam Flores conducted a complaint inspection and met with Charles Smith, Assistant Manager. The purpose of the inspection was to deliver the findings for the above complaint allegation. The Department has investigated the complaint alleging staff gave minor medication without a court order. LPA conducted interviews and obtained documentation.There were inconsistencies in the confidential interviews. Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and appeals rights were provided, along with a copy of this report and left at the facility with Charles Smith, Assistant Manager. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Sonia Sanchez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Charles Smith, Assistant Manager


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Sonia Sanchez conducted a complaint inspection and met with Nadia Smith, House Manager. The purpose of the inspection was to deliver the findings for the above complaint allegation. The Department has investigated the complaint alleging staff does not ensure a safe environment for minor. LPA conducted interviews and obtained documentation. There were inconsistencies in the confidential interviews. Although the allegations may have happened or is valid, there is not a preponderance of evidence to provide the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was left at the facility, along with appeal rights. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Sonia Sanchez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE FACILITY NAME: MICHIGAN HOUSEFACILITY NUMBER: 100406164

met_with: Nadia Smith, House Manager


raw_content:
Investigation Findings:
13This is an amendment visit only to remove the D-page issued during yesterday's (09/16/2025) complaint inspection. See below for original 9099. On the above date, Licensing Program Analyst (LPA) Sonia Sanchez conducted a complaint inspection and met with Nadia Smith, House Manager. The purpose of the inspection was to deliver the findings for the above complaint allegation. The Department has investigated the complaint alleging staff does not ensure a safe environment for minor. LPA conducted interviews and obtained documentation. There were inconsistencies in the confidential interviews. Although the allegations may have happened or is valid, there is not a preponderance of evidence to provide the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was left at the facility, along with appeal rights. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Sonia Sanchez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


summary: Facility Evaluation

raw_content:
Narrative:
On 2/11/2022, Licensing Program Analyst (LPA) Daiquiri Boyd, visited Michigan House to discuss an incident report that was sent in in August of 2021. LPM Angela King requested that LPA look into the incident and the facts of the incident. LPA spoke with Nadia Smith, House Manager, regarding the incident. Nadia Smith told LPA that on that day, the client came into the facility with his own electronics and was told they do not allow them here at this facility. The staff said that client made a comment that the Administrator had given permission to have the electronics, but they had not been made aware of this. Staff said that once the client calmed down and they were able to talk to staff Garnett, he admitted that he had told this client it was going to be allowed and that is was his fault that he did not make staff aware of this. The client was able to keep his electronics and they worked out a plan to ensure that this doesn't happen again.

met_with: Nadia Smith


summary: Facility Evaluation

raw_content:
Narrative:
On this date, March 9, 2022 at 09: AM, an unannounced required annual inspection was conducted by Licensing Program Manager (LPM), Juanita Arroyo and Licensing Program Analyst (LPA) Wayne Aoki. LPM and LPA were met facility Administrator . LPM and LPA inspected the facility, inside and out. Centrally stored medications and sharps are maintained in a locked file cabinet. LPA inspected the medications for the minors in care. The facility has a written emergency disaster plan. All facility smoke and carbon monoxide detectors were tested and appear to be in appropriate working order, fire extinguisher is properly charged and was last serviced July 7, 2021. Individual beds were observed with appropriate clean linens and are in good repair. There is at least one week supply of nonperishable and a two day supply of perishable foods. The facility is maintained at 69 degrees. Hot water temperature measured 117 degrees. Facility cameras are allowed in the facility and there are no pets. There were 4 staff present during this inspection. Both staff and minor's files reviewed. LPA interviewed 10 staff during the inspection. Interviews with staff and minors in placement were conducted. LPA reviewed the facility's disaster plan, sampled medication and reviewed facility logs. LPAs requested the following updated documents be sent to LPA, D. Boyd by March 16, 2022. LIC 308, LIC 309, LIC 400, LIC 500 and LIC 610C Facility cited for violation CCR 80087(g). A copy of this report was left at the facility at the conclusion of the inspection


summary: Facility Evaluation

raw_content:
Narrative:
On 05/20/2022, Licensing Program Analyst (LPA), Vanessa Galvan traveled to Michigan House in Fresno, CA and met the Assistant House Manager, Angel Mixon. The purpose of the visit was to conduct an interview with Client 1 (C1). C1 refused to be interviewed by LPA Galvan. No deficiencies were observed or cited. A copy of this report was left with Angel Mixon at the conclusion of the inspection.

met_with: Angel Mixon


summary: Facility Evaluation

raw_content:
Narrative:
On 06/01/2022, Licensing Program Analyst (LPA) Daiquiri Boyd and Wayne Aoki and Licensing Program Manager (LPM) Juanita Arroyo conducted an informal conference for the above facility with Administrator Staff of Michigan House and Michigan House 2. The purpose of the conference was to discuss the facility history and current operating procedures. Paperwork was presented to update all facilities with regard to Administrators. Procedures for handling incidents were discussed. Garnett stated that changes have been made through additional staffing and updated training for staff. The facility has reinstated better system for recording incidents and logging of those incidents and the process for reporting to Department of Behavioral Health. LPM discussed ensuring that CFT's are held and documented as well as the Mental Health Team meetings. Also discussed, was the need for better documentation for incident reporting as pre and post events, such as unauthorized absences. Discussed updated Mental Health and Accreditation dates. New contact information for all Administrators and staff will be sent to Licensing.

met_with: Garnett Fountain, Sena Streets, Richard Terry Streets


summary: Facility Evaluation

raw_content:
Narrative:
On January 11, 2023, Licensing Program Analyst (LPA) was met by facility manager Nadia Smith for the purpose of conducting a Case Management regarding an incident that occurred on June 26, 2022 regarding M1. M1 is no longer at the facility (6/6/22-11/30/22). During the incident it was reported that M1 broke the lock that was on his bicycle and left the facility without permission. LPA asked Ms. Smith why the minor's bicycle was locked. Ms. Smith explained that the minor requested the lock for his bicycle because the other residents in the home would use it and leave without permission on his bicycle. The facility staff purchased a lock for the minor. On June 26, 2022, the minor was upset and wanted to leave the facility without permission. The minor broke the lock off and did leave the facility. LPA asked Ms. Smith why would the minor have to break the lock off if he has the keys. Ms. Smith explained that the minors in the home do not keep their own keys. When they want their keys they request it from staff and staff will get it for them. LPA asked Ms. Smith if the bicycle was locked to prevent minor from leaving the facility without permission. Ms. Smith stated that the minor locks his own bicycle so others don't take it. They did not lock it up to prevent him from leaving the facility. On the day of the incident, minor was upset and didn't wait for the key and broke the lock off and then left. Ms. Smith explained to the LPA that staff is aware that they are not to lock up minor's personal belongings without their permission unless it is something they are not allowed to have in the home (contraband). There were no deficiencies cited during this Case Management for the incident of June 26, 2022


summary: Facility Evaluation

raw_content:
Narrative:
On August 3, 2023, Licensing Program Analyst (LPA) was met at the facility by Staff Charles Smith. Mr. Smith contacted Facility Manager, Nadia Smith which arrived at the facility shortly thereafter. The purpose for the inspection is to conduct a Case Management with regards to incident reports dated May 13, 2023 and May 14, 2023. Incident report dated May 13, 2023 stated that minor refused to take medication and lost points due to this. This incident report was also not signed by facility personnel. This incident report in question was vague with details and specifically stated that the minor lost points for not taking medication. Mr. Smith stated that he is the staff that is responsible for completing and submitting incident reports for the facility. Mr. Smith explained that he did not complete the incident reports in question as he was off on vacation during that time. Mr. Smith stated that the facility does not take away points for not taking medication and is not sure why that was put in the report. Ms. Smith stated that while Mr. Smith was out on vacation another staff completed the report. Ms. Smith agreed that this incident report was not properly completed with information and that clarification should had been stated that the loss of points was due to the disrespect (Inappropriate language) to staff and not because of not taking medication. Incident report dated May 14, 2023 was vague and lacked information for a complete incident report. AWOL protocols were followed but that was not conveyed in the report due to the incompleteness of the report. Ms. Smith also acknowledged that the reports were not signed and not reviewed before being submitted to Community Care Licensing. Ms. Smith stated that all staff will undergo re-training on incident report writing. An Advisory Note -Technical Violation was issued on this date, no deficiencies cited during this inspection.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program(LPA) Corina Carrillo conducted a case management inspection March 19, 2024 at 11:04AM, based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 5 out of Direct Care Staff and 3 out of 3 youth files were reviewed. 2 out of Direct Care Staff and 0 out of 3 youth were interviewed. (See the Confidential Names List, LIC 811, March 19, 2024.) The Plan of Operation including policies and procedures were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments and crisis intervention plans, the licensee uses trauma- informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Carrillo observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Nadia Smith.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Reyna Martinez on April 11, 2024 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPA met with Nadia Smith, Facility Manager and inspected the facility inside and out. LPA reviewed 1 child record and 2 staff personnel files on site at the facility. LPA reviewed 1 child psychotropic medications and medication records. LPA interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA was unable to interview 1 child currently on psychotropic medication due to child at school. LPA will attempt to interview 1 child at a later time. LPA provided a copy of the licensing report to Nadia Smith, Facility Manager. No deficiencies are being cited at this time. LPA conducted exit interview with Nadia Smith, Facility Manager.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by Licensing Program Analysts (LPAs), Lidia Tinoco and Miriam Flores traveled to the Michigan House STRTP in Fresno, CA. LPA met with Administrator, Nadia Smith. A physical plant inspection was completed and included the following checks. Facility grounds are clean and free of debris. Adequate indoor and outdoor activity space and materials observed. The facility is maintained at 72 degrees. All facility smoke detectors and carbon monoxide detectors are in appropriate working order. Facility maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. One client requires medications currently, facility has the ability to keep Medications locked and centrally stored. Individual beds were observed with appropriate clean linens and are in good repair. Licensee has obtained Mental Health Certification Including the following: Mental Health Program Approval is valid from September 21, 2023 through September 21, 2026. Licensee has obtained National Accreditation through CARF valid through August 31, 2025. The facility has a county contract valid through September 21, 2026. No firearms or weapons are allowed in the facility. Facility appears to be meeting the terms and conditions of their license. LPA reviewed 3 client files and 5 staff files. LPA conducted one client interview. Two client interviews and staff interviews will be conducted at a later date. Three Type B deficiencies were cited and three Technical Assistance were issued on today's date. A copy of this report was provided along with appeal rights at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On 4/22/2024, Licensing Program Analysts (LPAs), Miriam Flores and Lidia Tinoco arrived at Michigan House for the purpose of continuing the annual inspection and met with Assistant Facility Manager, Charles Smith. LPAs conducted interviews and record reviews. Staff interviews were conducted. One client was at home and two other clients are at school. The interviews will be conducted at a later time. The Administrator Certificate renewal for S1 is pending, verified by a call to ACS (Administrator Certification Section) made on 4/17/24. LPAs addressed the Program Statement revision and a time frame of two months was given to complete the revisions. Revision due by June 28, 2024. LPAs also observed the updated Personal Rights form to be posted. Updated Personal Rights were also signed and given to the youth in care. There are no deficiencies to be cited on this date. A copy of this report was provided on this date at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Melissa Renovato, arrived at Michigan House for the purpose of conducting an unannounced Case Management inspection and met with Karla Delgado, Direct Care Staff. LPA conducted a confidential interview with a client regarding a previous placement (See 812). No deficiencies were cited on this date. An exit interview was conducted, and a copy of this report was provided at the conclusion of the inspection.

met_with: Karla Delgado, Direct Care Staff


summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analyst (LPA) Sonia Sanchez conducted an unannounced case management visit at the STRTP and met with Nadia Smith, House Manager,Charles Smith, Assistant Manager, and Alex Lopez, Head of Service. The purpose of the inspection is to follow up on an IR sent to CCL email box on May 28, 2025 (0001812-FN) with client C1 (see LIC 811 dated 06/10/2025). The incident was discussed with staff. Staff provided LPA with CFT meeting notes, Needs and Service Plan, additional email correspondence. If further actions are needed, LPA will address at a later time. A copy of this report was discussed and provided to Nadia Smith at the STRTP.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Sonia Sanchez traveled to Michigan House, STRTP to conduct an unannounced inspection and met with Nadia Smith, House Manager. The purpose of the inspection was to conduct an interview with Client #1 (see LIC-811 dated 07/21/2025). LPA was unable to conduct the interview due to Client #1 refusing. If further actions are needed, LPA will address at a later time. There are no deficiencies to be cited on this date. A copy of this report was left at the facility with Nadia Smith, House Manager.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Sonia Sanchez conducted a case management inspection at Michigan House, STRTP and discussed the previous case management plan of correction visit on July 3, 2025. House Manager provided LPA with the updated Needs Service Plan for the all clients in Michigan House as requested during the initial case management visit on July 3, 2025. LPA will review the records. If further actions or additional information is needed LPA will address at a later time. There are no deficiencies to be cited on this date. A copy of this report was discussed and left at the facility with Nadia Smith, House Manager.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Briana Placencia on August 18, 2025 at 9:00am. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPA met with Nadia Smith, House Manager and inspected the facility inside and out. LPA reviewed 2 child's records and 2 staff personnel files on site at the facility. LPA reviewed 2 child's psychotropic medications and medication records. LPA interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA attempted to interview 1 child currently psychotropic medication. The other child is currently at school LPA will interview youth at a later time. LPA provided a copy of the licensing report to Nadia Smith, House Manager. No deficiencies are being cited at this time. LPA conducted an exit interview with Nadia Smith, House Manager.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Sonia Sanchez met with Nadia Smith, House Manager to conduct an unannounced case management inspection in response to an incident report received by the Department on 09/09/2025. The purpose of the visit is to follow up on an incident that occurred on 09/08/2025 with Client (C1) and Client (C2) (See LIC Confidential Names List). LPA discussed with House Manager on 09/16/2025 at 1:00pm. Nadia Smith will provide LPA with CFT meeting notes from the CFT meeting that was held on 09/15/2025 via email once received. If further actions are needed, LPA will address at a later time. There are no deficiencies to be cited at this time. A copy of this report was discussed and provided to Nadia Smith at the STRTP.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analysts (LPAs) Sonia Sanchez and Miriam Flores traveled to Michigan House to conduct an unannounced case management visit and met with Charles Smith, Assistant House Manager. The purpose of the inspection was to follow up on two incident reports, dated 5/27/25 and 6/22/25. LPA is following up on the initial inspection that was completed on 06/10/2025 for incident report dated 5/27/25 with House Manager, Assistant House Manager, and Head of Service regarding Reporting Requirement and Searches. A follow up was conducted for incident report dated 6/22/25 to follow up on Reporting Requirements. A Technical Violation will be given on this date for ILS 87061. Based on record review and staff interviews, Staff 1 and Staff 2 (see LIC 811 dated 07/03/2025) conducted an unreasonable search on C1 (see LIC-811 dated 07/03/2025) upon returning from an AWOL for incident report dated 5/27/25.The Department determined this to be an immediate risk to health and safety at this time, therefore the FFA is being cited on the attached LIC809-D under Interim Licensing Standards, Section 87072(c)(10) Personal Rights. Effective 07/03/2025, Licensee will cease all searches until proper documentation is noted on Needs and Service Plan for Michigan House #1 and Michigan House #2. Licensee will also update Program Statement to reflect Personal Rights and on any other sections that are applicable for searches for both houses by August 3, 2025. An exit interview was conducted and a copy of this report, 809-D, and LIC9102, and appeal rights were discussed and provided to Charles Smith, Assistant House Manager at the STRTP.

met_with: Charles Smith, Assistant House Manager


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Sonia Sanchez met with Nadia Smith, House Manager (HM) and Charles Smith, Assistant House Manager (AHM) at the STRTP to conduct an unannounced case management inspection. The purpose of the inspection is to follow up on an incident that occurred on July 23, 2025 with Client #1 and Staff #1 and Staff #2 (see LIC 811, dated 08/06/2025). Staff #1 performed a Prone Restraint on Client #1. The incident was discussed with HM. HM provided LPA Restraint training logs for Staff #1 and Staff #2. The Department determined this to be an immediate risk to health and safety at this time. LPA discussed Personal Rights violation and Prone Restraints with the STRPT staff during a previous visit on July 3, 2025, therefore the STRTP is being cited on the attached LIC809-D under Interim Licensing Standards, Section 87095.01(a)((5) Prone Restraint, Section 87095.00(c)(6) General Provisions, as well as being issued a civil penalty for 87072(c)(1) Personal Rights. An exit interview was conducted, a copy of the report and appeal rights were discussed and provided to AHM at the STRTP.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Sonia Sanchez met with Charles Smith, Assistant House Manager (AHM) at the STRTP to conduct an unannounced case management inspection. The purpose of the inspection is to follow up on an incident report that was received in the CCL inbox on July 31, 2025, with the incident occurring on July 17, 2025 between Client 1 and Client 2 (see LIC-811, dated 08/06/2025). Based on record review, the STRTP did not report the incident to CCL within the specified time frame. The Department determined this to be an immediate risk to health and safety at this time, therefore the STRTP is being cited on the attached LIC809-D under Interim Licensing Standards, Section Reporting Requirements. An exit interview was conducted, and a copy of the report and appeal rights were discussed and provided to the AHM at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 05/12/2022, an unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Tamara Melikian and Vanessa Galvan at 10:00AM. During the inspection, LPAs met with House Manager Nadia Smith and inspected the facility inside and out. LPAs reviewed two children's records and reviewed two staff personnel records for the facility. LPAs interviewed one staff at 11: AM, the Administrator was unable to be at the inspection and will be interviewed at a later date. The children were at school on this date and will be interviewed at a later date. A medication review was conducted at 11: AM. LPAs conducted exit interview with Nadia Smith, House Manager at 12: PM. Deficiency on the attached page.


summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analyst's (LPAs) Miriam Flores and Reyna Martinez conducted a case management visit at the STRTP and met with Nadia Smith, Facility Manger (FM). The purpose of the meeting was to discuss an incident report emailed to Community Care Licensing (CCL) on March 5, 2024. LPA confirmed the incident that occurred on March 8, 2024 and reporting date. Staff (S1) (see attached LIC811) failed to administer client (C1) psychotropic medication as directed by prescribing physician. Based on the information obtained, the STRTP is being issued a deficiency under Code of Regulations (CCR), Title 22, 87075(c) Health Related Services on the attached LIC809-D. A copy of this report and appeal rights was left with Nadia Smith, Facility Manager.


summary: Facility Evaluation

raw_content:
Narrative:
On 02/10/2026, Licensing Program Analyst (LPA) Sonia Sanchez travelled to the above facility to conduct an Annual Random inspection. Met by House Manager (HM) Nadia Smith, Assistant House Manager (AHM) Charles Smith. At 9:00AM - 9:30AM, an inspection of the physical plant was conducted. LPA observed adequate food supply, adequate bedding, storage space, activity space, a properly charged fire extinguisher, two first aid kits, hot water that initially measured 127 degrees, but was lowered by AHM at time of visit, as well as toiletries and a facility that is safe, sanitary and in good repair. At 9:30AM - 10:45AM, an inspection of client files was conducted as well as the centrally stored record and medications. At 10:45AM - 11AM, an inspection of the Disaster Preparedness Binder and training records were conducted. At 11AM - 12:00PM, staff records were inspected. At 12:00 - 12:30PM, three staff interviews and one client interview was conducted. The exit interview was conducted at 1:30PM and a copy of this report given to the AHM. It is requested that the licensee submit the most recent minutes for the Board of Directors meeting. There are no deficiencies to be cited on this date


facility_name: MICHIGAN HOUSE #2

raw_content:
Investigation Findings:
13On October 14, 2022, Licensing Program Analyst (LPA) Wayne Aoki conducted a follow up complaint inspection. The purpose of the inspection is close and deliver the findings for the above complaint allegation. LPA was me by facility representative Monique Cannon. During the course of the investigation, confidential interviews were conducted and copies of documents were obtained. Although the allegation may have happened or is valid, there is not a preponderance of the evidence, therefore, the above allegation is unsubstantiated. Based on the above, the complaint is Unsubstantiated. There were no deficiencies cited during this inspection. A copy of this report was left with the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Wayne Aoki LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Monique Cannon


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On August 3, Licensing Program Analyst (LPA) was met by facility representative Will Hayes. The purpose for this inspection is to seek additional information and conduct interviews with the minors in care. LPA previously obtained copies of Needs and Services Plans, Admission agreements and client roster for the facility on August 2, 2023. LPA conducted interviews with three of the four minors in care. 1 minor was attending summer school during this inspection. Based on confidential interviews with staff and minors along with record review, there is a preponderance of the evidence to prove the above allegation is substantiated. The facility is being cited for a violation of Interim Licensing Standards STRTP, Title 22, Division 6, Section 87061(b-f) Reporting Requirements An exit interview was conducted with Will Hayes and a copy of this report, and appeal rights were provided. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Wayne Aoki LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SIERRA CASCADE AC/SC, E SHAW AVE FACILITY NAME: MICHIGAN HOUSE #2FACILITY NUMBER: 107202606

met_with: Will Hayes


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Sonia Sanchez traveled to Michigan House #2 located in Fresno, CA to conduct an unannounced complaint inpsectoin and met with Roc Green, Assistant House Manager. The purpose of the inspection was to deliver the findings for the above complaint allegation. Based on interviews it was determined that staff spoke inappropriately to minor. Based on the LPA's confidential interviews and records review which were conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be substantiated. A deficiency is being cited for the Interim Licensing Standards (ILS) Chapter 8.8, Articles 6, Section 87072(c)(1) Personal Rights. A copy of the report and Appeal Rights were discussed and provided to Roc Green, Assistant House Manager at the STRTP. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Sonia Sanchez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE FACILITY NAME: MICHIGAN HOUSE #2FACILITY NUMBER: 107202606

met_with: Roc Green


summary: Facility Evaluation

raw_content:
Narrative:
On this date, March 24, 2022 at 09: AM, an unannounced required annual inspection was conducted by Licensing Program Analyst (LPA) Wayne Aoki. LPA was met by Assistant House Manager, Monique Cannon . LPA inspected the facility, inside and out. Centrally stored medications and sharps are maintained in a locked file cabinet. LPA inspected the medications for the minors in care. The facility has a written emergency disaster plan. All facility smoke and carbon monoxide detectors were tested and appear to be in appropriate working order, fire extinguisher is properly charged and was last serviced July 7, 2021. Individual beds were observed with appropriate clean linens and are in good repair. There is at least one week supply of nonperishable and a two day supply of perishable foods. The facility is maintained at 70 degrees. Hot water temperature measured 112 degrees. Facility cameras are allowed in the facility and there are no pets. There are no firearms in the facility and no bodies of water. There were 3 staff present during this inspection. Both staff and minor's files reviewed. Interviews with staff and minors in placement were conducted .LPA interviewed 3 staff and 2 minors during the inspection. LPA reviewed the facility's disaster plan, sampled medication and reviewed facility logs. LPAs requested the following updated documents be sent to LPA, D. Boyd by March 31, 2022. LIC 308, LIC 309, LIC 400, LIC 500 and LIC 610C There were no deficiencies cited during this inspection. A copy of this report was left at the facility at the conclusion of the inspection


summary: Facility Evaluation

raw_content:
Narrative:
On 07/22/2022, an unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian at 8:45AM. During the inspection, LPA met with Administrator Sena Streets, House Manager Will Haynes and staff member Monique Cannon and inspected the facility inside and out. LPA reviewed two children's records and reviewed two staff personnel records for the facility. LPA interviewed two staff at 10: AM. LPA interviewed two children at 10:20AM. A medication review was conducted at 10:45AM. LPA conducted exit interview with Sena Streets, Administrator at 11: PM. A copy of this report was given to Sena Streets, Administrator on this date.

met_with: Sena Streets, Will Haynes, Monique Cannon


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Jessica Rodriguez on July 24, 2023, at 9: A.M. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9(a)(2). During the inspection, LPA Rodriguez met with Assistant Manager, Monique Cannon and inspected the facility inside and out. LPA reviewed 4 of 4 child's records and 2 of 2 staff personnel files on site at the facility. LPA reviewed 4 of 4 child's psychotropic medications and medication records. LPA interviewed 2 of 2 staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 3 of 4 children currently prescribed psychotropic medication. LPA will interview the last child at another time, due to not being at the facility. No deficiencies are being cited at this time. LPA conducted exit interview with Assistant Manager, Monique Cannon. LPA provided a copy of this licensing report to Assistant Manager.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, An unannounced annual inspection was conducted by Licensing Program Analysts (LPAs), Lidia Tinoco and Miriam Flores at the Michigan House STRTP in Fresno, CA. LPAs met with Administrator, Sena Streets. A physical plant inspection was conducted and included the following checks. Facility grounds are clean and free of debris. Adequate indoor and outdoor activity space and materials observed. The facility is maintained at 72 degrees. All facility smoke detectors and carbon monoxide detectors are in appropriate working order. Facility maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. 3 clients require medications currently, facility has the ability to keep Medications locked and centrally stored. Individual beds were observed with appropriate clean linens and are in good repair. LPA discussed with Administrator the Program Statement and Plan of Operation updates to reflect the most updated regulations. The program currently has a due date of June 28, 2024. If more time is needed, Administrator will notify assigned LPA prior to the due date. Licensee has obtained Mental Health Certification Including the following: Mental Health Program Approval is valid from September 18, 2023 through September 17, 2024. Licensee has obtained National Accreditation through CARF valid through August 31, 2025. No firearms or weapons are allowed in the facility. Facility appears to be meeting the terms and conditions of their license. LPA reviewed 4 client files and 5 staff files. LPA conducted three client interviews and two staff interviews. One Type B deficiency was cited (See LIC809D) and two Technical Assistance (See LIC9102) were issued on this date. A copy of this report was provided along with appeal rights at the conclusion of the inspection.

met_with: Sena Streets


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPAs) Reyna Martinez and Briana Placencia on July 3, 2024 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPAs met with Sena Streets, Administrator and inspected the facility inside and out. LPAs reviewed 1 child record and 2 staff personnel files on site at the facility. LPAs reviewed 1 child psychotropic medications and medication records. LPAs interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPAs were unable to interview 1 child currently on psychotropic medication due to child at school. LPAs will attempt to interview 1 child at a later time. LPAs provided a copy of the licensing report to Sena Streets, Administrator. No deficiencies are being cited at this time. LPAs conducted exit interview with Sena Streets, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On 07/09/2024, Licensing Program Analyst (LPA) Reyna Martinez conducted a case management inspection, and met with Roc Green, Assistant Manager. The purpose of the inspection was to conduct an interview with Client (C1) (see LIC 811 attached) for the purpose of the SB Psychotropic Medication Inspection Client interviews. LPA provided a copy of the licensing report to Roc Green, Assistant Manager. No deficiencies are being cited at this time. LPA conducted exit interview with Roc Green, Assistant Manager.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Sonia Sanchez conducted an unannounced case management inspection at Michigan House #2 and met in-person with Shardae Thomas, Direct Care Staff (DCS) and Will Haynes, House Manager (HM) by phone. The purpose of the inspection is to follow up on a fingerprint clearance for staff 1 (see LIC811, dated 01/06/2026). The fingerprint clearance was discussed with HM. HM will follow up with Michigan House # Human Resources to get details of the fingerprint clearance, as well as contact Guardian to check what is needed for the CACI clearance. HM will keep in contact with LPA and provide updates as they become available. HM advised LPA, S1 is not scheduled to report back to work until Friday, January 9, 2026 and if HM doesn't have an update by then, S1 will not report to MH2. If further actions are needed, LPA will address at a later time. There are no deficiencies to be cited on this date. A copy of this report was discussed with DCS and HM and provided to DCS.

met_with: Shardae Thomas


summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analyst's (LPAs) Miriam Flores and Reyna Martinez conducted a case management visit at the STRTP and met with Will Haynes, Facility Manger (FM). The purpose of the meeting was to discuss an incident report emailed to Community Care Licensing (CCL) on March 5, 2024. LPA confirmed the incident that occurred on February 24, 2024 and reporting date. Licensee failed to submit the incident to the licensing within seven days following the occurrence of the incident. Based on the information obtained, the STRTP is being issued a deficiency under Code of Regulations (CCR), Title 22, 80061(b) Reporting Requirements on the attached LIC809-D. A copy of this report and appeal rights was left with Will Haynes, Facility Manager.

met_with: Will Haynes


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Sonia Sanchez, conducted an unannounced annual inspection at the above agency. LPA met with Will Haynes, House Manager and Shardae Thomas, Direct Care Staff. A physical plant inspection was conducted and included the following checks. Facility grounds are clean and free of debris. Adequate indoor and outdoor activity space and material observed. The facility is maintained at 72 degrees. All facility smoke detectors and carbon monoxide detectors are in appropriate working order. Facility maintains an adequate supply of perishable and non-perishable foods. Facility has ability to keep medications locked and centrally stored. Individual beds were observed with appropriate clean linens and in good repair. Licensee has obtained Mental Health Certification including the following: Mental Health Program Approval is valid from September 17, 2025 through September 17, 2026. Licensee has obtained National Accreditation through CARF valid through August 31, 2028. No firearms or weapons are allowed in the facility. Facility appears to be meeting the terms and conditions of their license. LPA reviewed 5 staff files and 4 client files. LPA conducted three staff interviews and two client interviews. One Type B deficiency was cited for 80087(a) Buildings and Grounds. A copy of this report was discussed and provided along with appeal rights to House Manager, Will.

met_with: Will Haynes, House Manager


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Sonia Sanchez conducted a complaint inspection and met with Shardae Thomas, Direct Care Staff (DCS) and Will Haynes, House Manager (HM). The purpose of the inspection was to deliver the finding for the above complaint allegation. Based on interviews it was determined that the facility admitted a client under the age of 13. Based on the LPA's confidential interviews and record review which were conducted, the preponderace of evidence standard has been met, therefore, the above allegation is found to be substantiated. A deficiency is being cited for the General Licensing Section 80010, Limitations on Capacity and Amubulatory Status. A copy of this report and appeal rights were discussed and provided to Shardae Thomas at the STRTP. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Vanessa Galvan LICENSING EVALUATOR NAME: Sonia Sanchez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE FACILITY NAME: MICHIGAN HOUSE #2FACILITY NUMBER: 107202606


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Sonia Sanchez conducted a complaint inspection and met with Shardae. The purpose of the inspection was to deliver the findings for the above complaint allegations. The Department has investigated the complaint alleging staff physically assualted youth resulting in injury, and staff verbally threatened youth. LPA conducted interviews and obtained documentation. There were inconsistencies in the confidential interviews. Although the allegations may have happened or is valid, there is not a preponderance of evidence to provide the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report and appeal rights were discussed and left at the facility with Shardae. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Sonia Sanchez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE This is an official report of an unannounced visit/investigation of a complaint received in our office on 12/23/2025 and conducted by Evaluator Sonia Sanchez PUBLICCOMPLAINT CONTROL NUMBER: 24-CR- FACILITY NAME:MICHIGAN HOUSE #2FACILITY NUMBER: ADMINISTRATOR:SENA STREETSFACILITY TYPE: ADDRESS: S. HUGHES AVENUETELEPHONE: (559) 233- CITY:FRESNOSTATE: CAZIP CODE: CAPACITY:6CENSUS: 4DATE: 02/23/ UNANNOUNCEDTIME BEGAN: 08: AM MET WITH:Shardae ThomasTIME COMPLETED:09: AM 9Staff did not follow reporting requirements INVESTIGATION FINDINGS: 13On the above date, Licensing Program Analyst (LPA) Sonia Sanchez conducted a complaint inspection and met with Shardae Thomas, Direct Care Staff. The purpose of the inspection was to deliver the findings for the above complaint allegation. Based on interviews it was determined that staff did not follow reporting requirements. Based on the LPA's observations, confidential interviews and records review which were conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be substantiated. A deificiency is being cited for the Interim Licensing Standards (ILS) Section 87061(i) Reporting Requirements. A copy of the report and appeal rights were discussed and provided to Shardae Thomas, Direct Care Staff at the STRTP. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Sonia Sanchez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 2 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE This is an official report of an unannounced visit/investigation of a complaint received in our office on 12/23/2025 and conducted by Evaluator Sonia Sanchez PUBLICCOMPLAINT CONTROL NUMBER: 24-CR- FACILITY NAME:MICHIGAN HOUSE #2FACILITY NUMBER: ADMINISTRATOR:SENA STREETSFACILITY TYPE: ADDRESS: S. HUGHES AVENUETELEPHONE: (559) 233- CITY:FRESNOSTATE: CAZIP CODE: CAPACITY:6CENSUS: 4DATE: 02/23/ UNANNOUNCEDTIME BEGAN: 08: AM MET WITH:Shardae ThomasTIME COMPLETED:09: AM 9Staff did not follow reporting requirements INVESTIGATION FINDINGS: 13On the above date, Licensing Program Analyst (LPA) Sonia Sanchez traveled to Michigan House #2 to conduct a complaint inspection and met with Shardae Thomas, Direct Care Staff. The purpose of the inspection was to deliver the findings for the above complaint allegation. Based on record review and confidential interviews it was determined that staff did not follow reporting requirements. Based on record review and confidential interviews which were conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be substantiated. A deificiency is being cited for the Interim Licensing Standards (ILS) Section Reporting Requirements. A copy of the report and appeal rights were discussed and provided to Shardae Thomas at the STRTP. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Sonia Sanchez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 3 of Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE FACILITY NAME: MICHIGAN HOUSE #2FACILITY NUMBER: 107202606


summary: Complaint Investigation - Unsubstantiated - 1 deficiency

raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Sonia Sanchez conducted a complaint inspection and met with Shardae Thomas, Direct Care Staff (DCS) and Will Haynes, House Manager. The purpose of the inspection was to deliver the finding for the above complaint allegation. The Department has investigated the complaint alleging client is not receiving therapeutic services and client is not attending school. LPA conducted interviews and obtained documentation. There were inconsistencies in the confidential interviews. Although the allegations may have happened or is valid, there is not a preponderance of evidence to provide the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report and appeal rights were discussed and provided to Shardae Thomas, DCS at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Vanessa Galvan LICENSING EVALUATOR NAME: Sonia Sanchez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE This is an official report of an unannounced visit/investigation of a complaint received in our office on 12/22/2025 and conducted by Evaluator Sonia Sanchez PUBLICCOMPLAINT CONTROL NUMBER: 24-CR- FACILITY NAME:MICHIGAN HOUSE #2FACILITY NUMBER: ADMINISTRATOR:SENA STREETSFACILITY TYPE: ADDRESS: S. HUGHES AVENUETELEPHONE: (559) 233- CITY:FRESNOSTATE: CAZIP CODE: CAPACITY:6CENSUS: 2DATE: 03/09/ UNANNOUNCEDTIME BEGAN: 10: AM MET WITH:Shardae ThomasTIME COMPLETED:11: AM 9Client was vaccinated without proper consent INVESTIGATION FINDINGS: 13On the above date, Licensing Program Analyst (LPA) Sonia Sanchez conducted a complaint inspection and met with Shardae Thomas, Direct Care Staff (DCS) and Will Haynes, House Manager. The purpose of the inspection was to deliver the findings for the above complaint allegation. Based on interviews it was determined that client was vaccinated without proper consent. Based on the LPA's confidential interviews and record review which were conducted, the preponderace of evidence standard has been met, therefore, the above allegations are found to be substantiated. A deficiency is being cited for the Interim Licensing Standards (ILS) Chapter 7.5, Article 6, Section 87070(b)(12) Children's Records. A copy of this report and appeal rights were discussed and provided to Shardae Thomas, DCS at the STRTP. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Vanessa Galvan LICENSING EVALUATOR NAME: Sonia Sanchez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 2 of Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE FACILITY NAME: MICHIGAN HOUSE #2FACILITY NUMBER: 107202606

Deficiencies:
70701: (12) Consent forms,... by the child's authorized representative(s), to permit the facility to authorize medical care.

title:
2
3
4
5
6
787070 Children's Records
(b) ... regarding the child shall be obtained and maintained in the child's record


summary: Facility Evaluation

raw_content:
Narrative:
On 04/23/2026, Licensing Program Analyst (LPA) Sonia Sanchez traveled to Michigan House 2 in Fresno, CA to conduct an unannounced case management inspection and met with Roc Green, Assistant Manager. The purpose of the inspection is to discuss an incident report (2918-FN) that was submitted to the department on 04/16/2026. On 04/15/2026, Staff (S1) (see LIC 811 for confidential names list) observed Client (C1) entering another clients (C2) room, staff verbally redirected C1 to come out of C2's room, which C1 complied, however C1 again entered into C2's room. Due to previous sexualized behaviors from C1, S1 attempted to redirect C1 again, when C1 became verbally and physically abusive toward S1. There are no deficiencies to be cited on this date. A copy of this report is discussed and left with Roc Green, Assistant Manager.

met_with: Roc Green, Assistant Manager


facility_name: MILE HIGH LEGEND HOME

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced complaint investigation inspection at the facility and met with staff Beverly Knox (S1) who assisted with the inspection. The Department's Investigations Branch Investigator, Blake Williams (IB), investigated this complaint by conducting confidential interviews with the Administrator, County Social Worker, three staff, and five children on 8/30/2021, 9/23/2021, 9/24/2021, 9/28/2021, and 10/6/2021. IB found that a child involved has a history of making up accusations when he does not get his way, and the child was unable or unwilling to give any details about the allegation. The accused staff denied the allegation, and other children interviewed also denied the allegation occurred. Based on all interviews IB found that there was not a preponderance of the evidence to prove that the allegation did or did not occur, therefore the allegation is found to be Unsubstantiated. An exit interview was conducted with S1 and a copy of this report along with appeal rights was emailed to her with a read receipt which will serve as the record of receipt. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Alyssa M Burgess LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

met_with: Beverly Knox, Steve Dogan


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
During the investigation, LPA Baca investigated the complaint Minor was sexually abused by another minor while in care. Interviews with Admin, Staff 1, Staff 3, Director, FY1 and Administrator stated that when staff were called downstairs for a crisis with another youth in the house, in where Staff1 no longer had an eyesight on the upstairs hallway, FY3 took advantage of the situation and went into FY1 and FY2 bedroom, sat on the bed and rubbed FY1 leg and himself while getting an erection and the tip of his penis was briefly seen by FY1, FY1 asked FY3 to leave and FY3 left. After several days FY1 and FY2 told staff about the incident while at an outing, and FY3 was moved to the other facility the same day in Fairfield until his probation officer picked him up. Interview with FY3 stated that nothing happened in the room and refused to talk to LPA about anything Interview with probation officer stated that she believed the incident happened, however does not believe it was to harm FY1. This allegation has been found to be UNSUBSTANTIATED meaning that allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

Investigation Findings:
13Licensing Program analyst (LPA) Jennifer Baca arrived at the agency to conduct an unannounced complaint inspection on 9.22.2022 at 10:00Am. LPA Baca spoke with Steve Dogan , Administrator to discuss the findings of the complaint investigation and allegation stated above. LPA informed agency staff this case was investigated by LPA Baca. The initial 10-day complaint investigation inspection was conducted at the agency on 8.9.2022, by LPA Johnson Documents received for staff included the following: Staff roster, Staff phone numbers and Staff schedule. Documents regarding foster Youth included the following: Needs and services. Interviews were conducted with Director 9.7.2022, Staff 1 on 9.9.2022, Administrator 9.9.2022, Staff 2 on 9.9.2022, Staff 3 on 9.12.2022, FY1 on 8.9.2022, FY3 on 9.21.2022, Probation officer on 9.13. LPA was unable to interview Reporting party after multiple attempts of contacting and leaving a return number. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Jennifer Baca LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MILE HIGH LEGEND HOMEFACILITY NUMBER: VISIT DATE: 09/21/2022

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

met_with: Steve Dogan, Administrator


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Both the client and staff denied that there was any romantic relationship between them. On 2/6/2023, C1 left the facility without permission and ED followed the client to an apartment. ED knocked on the door and S1 answered the door. ED told S1 to have C1 come out, however S1 lied and denied that C1 was there. In S1's interview she informed IB this was because she wanted to help C1. ED stated he would call Law Enforcement if C1 did not come out and C1 did come out. S1 was immediately terminated. Interviews with one client revealed that S1 and C1 would often be together in areas of the facility which cameras do not reach, and which are restricted to staff-only, such as the medication room and the laundry room. One staff interviewed stated that S1 did spend time in the laundry room to take breaks. Also revealed in the client's interview was that C1 would make inappropriate gestures about S1, such as a, "butt-smacking," gesture, and described S1 and C1's relationship as, "weird." There were no disclosures from anyone interviewed that there was a sexual or romantic relationship between S1 and C1. Based on IBs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Health and Safety Code Section 1558(a)(2) is being cited on the attached LIC 9099D. An exit interview was conducted with FM and a copy of this report and appeal rights was left with him.

Investigation Findings:
13Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced complaint investigation inspection at the facility and met with Facility Manager (FM) Steven Anderson, who assisted with the inspection. CCL's Investigations Branch Investigator (IB) Jeff LaGrange investigated this complaint by reviewing personnel records, complaint history, and a police incident report, and by conducting confidential interviews with the Executive Director, Administrator of another facility, three staff, and four clients on 2/15/2023, 4/14/2023, and 4/17/2023. Based on these reviews and interviews, IB found that on 2/6/2023, one client was found in the personal residence of staff (S1, see Confidential Names List dated 5/10/2023). Executive Director, the involved staff, and the involved client (C1) confirmed this to be true. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Alyssa M Burgess LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MILE HIGH LEGEND HOMEFACILITY NUMBER: VISIT DATE: 05/10/2023

met_with: Steven Anderson


raw_content:
Narrative:
It was confirmed during a conversation with the Administrator on 4/18/2023, that the electricity to the house was turned off by staff around 10: PM, one night. The reason giving was "the kids should have been in bed at that time and weren't'. C1 also disclosed during a confidential interview that the electricity to the whole house had been turned off. A client interviewed during an Annual Inspection, disclosed the same when asked about the electricity being turned off. There was also a video sent by C1's Case Manger confirming the electricity was turned off as well. It was also confirmed by clients and staff that the electricity to the outlet plugs in the kitchen are turned off. This is to prevent clients from charging their cell phones. Clients sign a contract that they will not have a personal cell phone until they reach a certain level. This is not in the Program Statement or addressed in their Needs and Service Plans. However, C1's cell phone was not taken by staff and remained in C1's possession. There is a phone in the house, that all clients can use to call social worker, lawyers and for their own personal use. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1 80072(a)(2), are being cited on the attached LIC 9099D." An exit interview was conducted on 5/10/2023, the report/appeal process were reviewed with the Manager. A copy of this report/appeal rights were emailed to the Administrator, Steve Dogan due to technical difficulties.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton arrived at the home to delivery findings on a unannounced complaint investigation on 5/10/2023. LPA Mary Shelton spoke with the Manager, to discuss the findings of the complaint investigation and allegation stated above. The initial 10-day complaint investigation inspection was conducted by LPA Mary Shelton at the facility on 3/7/2023. Copies of facility documentation were provided to LPA that included: Rules Package, Personal Rights, Facility Policies, Bedtime Rules, House Policy, Visitation Rules & Policy, Phone Policy, Sign Out Procedure, School Attendance Policy, Level System, Discipline Policies, Children's Complaint/Grievance Procedures, Theft and Loss Policy, Contraband Search Policy, Register of Facility Clients/Residents, Personnel Report, Client's Needs and Service Plan, Behavioral Health Needs & Service Plan, staff training records, Case Notes and Incident Reports. Interviews were conducted with clients, social workers, Behavior Specialists, Direct Care Staff, Administrator and both the Executive Director and Program Director between 3/7/2023 and 4/28/2023. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Mary Shelton LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MILE HIGH LEGEND HOMEFACILITY NUMBER: VISIT DATE: 05/10/2023

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

met_with: Manager, Steven Anderson


raw_content:
Narrative:
Allegation: Staff locked minors out of facility for an extended period of time. It was determined during the investigation that C1 was not locked out of the house for an extended period. The incident was discussed in C1's latest, CFT Meeting. The County Supervising Social Worker stated the incident was embellished and C1 was not locked outside. This discussion occurred in the presence of C1. The Supervising Social Worker was present during the meeting and stated that she talked to C1 outside the home and stated C1 could of went back in the home as well. C1 felt he was locked out due to staff wanted C1 to turn in C1's cell phone. However, C1 did keep his phone and came inside the home after returning from an AWOL. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff did not provide food and water to minor. It was determined during confidential interviews with Direct Care Staff and Behavioral Specialist staff that C1 was offered food/water when C1 was outside the home. The County Supervising Social Worker was on the phone when C1 was ordering food from Panera Bread. C1 choose to leave the home and get food from Panera Bread. All clients interviewed stated there was food in the home and available when they wanted to eat. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff did not allow minor to use bathroom. It was determined during interviews with clients and staff that C1 could have entered the home to use the bathroom. Staff and clients stated during interviews they could use the restroom whenever they wanted. During C1's interview he never stated C1 could not use the bathroom while outside. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No title 22 regulations were cited during today's inspection. An exit interview was conducted on 5/10/2023, the report/appeal process were reviewed with the Manager. A copy of this report/appeal rights were emailed to the Administrator, Steve Dogan due to technical difficulties.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton arrived at the home to delivery findings on an unannounced complaint investigation on 5/10/2023. LPA Mary Shelton spoke with the Manager, to discuss the findings of the complaint investigation and allegation stated above. The initial 10-day complaint investigation inspection was conducted by LPA Mary Shelton at the facility on 3/7/2023. Copies of facility documentation were provided to LPA that included: Rules Package, Personal Rights, Facility Policies, Bedtime Rules, House Policy, Visitation Rules & Policy, Phone Policy, Sign Out Procedure, School Attendance Policy, Level System, Discipline Policies, Children's Complaint/Grievance Procedures, Theft and Loss Policy, Contraband Search Policy, Register of Facility Clients/Residents, Personnel Report, Client's Needs and Service Plan, Behavioral Health Needs & Service Plan, staff training records, Case Notes and Incident Reports. Interviews were conducted with clients, social workers, Behavior Specialists, Direct Care Staff, Administrator and both the Executive Director and Program Director between 3/7/2023 and 4/28/2023. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Mary Shelton LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MILE HIGH LEGEND HOMEFACILITY NUMBER: VISIT DATE: 05/10/2023

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


raw_content:
Narrative:
Interviews with all staff members, FM, S1, S5, and S6, stated that the only time a staff member stays the night at the facility, is if they are working an overnight shift. Additionally, when asking the youth (C1, C2, C3, and C4) if they had ever seen a staff member do drugs at the facility, they all stated, no, never. This Department has investigated the complaint alleging that staff engaged in drug activity in the home posing a risk to minors in care. We have found that the complaint is Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with the Jose Reyes. A copy of this report, and appeal rights were given.

Investigation Findings:
13On Wednesday, January 15th, 2024 at 12PM, Licensing Program Analyst (LPA) Brittany Crass, made an unannounced complaint investigation inspection at the facility, to deliver findings for the allegation listed above. LPA met with the Residential Counselor, Jose Reyes, who assisted with the inspection. LPA conducted the initial-10 day complaint investigation at the Facility on 12/10/2024. Between 12/10/24 and 1/6/25, LPA interviewed four youth (C1, C2, C3, and C4), four staff members (FM, S1, S5, and S6), and the Administrator (S4). LPA was unable to get ahold of the Reporting Party. It was alleged that a staff member had been using the facility as their personal living space and doing drugs at the facility. During confidential interviews, both youth and staff appeared to be surprised by this allegation, and all denied it occurring. (continued on LIC 9099-C). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Brittany Crass LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MILE HIGH LEGEND HOMEFACILITY NUMBER: VISIT DATE: 01/15/2025

met_with: Jose Reyes