facility_name: SUMMITVIEW CHILD AND FAMILY SERVICES - LOTUS

raw_content:
Narrative:
cognitive development, social development, cleanliness, gender identity, and sexual orientation of each youth to determine if they are compatible or not. Compatibility assessments also include discussion with each youth when they are admitted or if a youth needs to be switched rooms. Confidential interviews conducted revealed that these youth were in a previous placement prior to coming to this facility and were familiar with one another. When the opportunity presented itself for either of the youth to switch rooms, the youth refused to move rooms or to stop being roommates. The allegation that staff did not prevent minors from possessing restricted items is related to the agency policy prohibiting items containing alcohol to be in youths' possession and prohibiting that youth be in possession of items that youth could use to cause self harm, including sharp objects. The agency policy dictates youth must lock up these items with their hygiene items that contain alcohol. During the facility inspection, it was noted that C3 did have two bottles of perfumed body sprays in their restroom that were not locked according to this policy. Review of C3's Needs and Services Plan does not indicate that these items pose a danger to C3 and therefore C3 has a right to have these items in their possession. While the agency policy is to have these items locked, there is no regulation stating that youth cannot safely manage these items. Regarding having other dangerous items in youths' possessions including sharp objects, LPA Hill did not observe other dangerous items accessible to youth as reported. Confidential interviews indicated that sharp items are locked up and not accessible to youth in care. As a result of the investigation conducted including interviews conducted and documents reviewed, the allegations that staff did not ensure minors sharing a room were compatible and that staff did not prevent minors from possessing restricted items are UNSUBSTANTIATED at this time meaning the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview was conducted and documents were provided along with appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced complaint inspection on 7/17/25 at 12: PM and met with Haley Randle, Director of Youth Residential Programs to discuss the stated complaint allegations. LPA Hill informed Ms. Randle that the investigation included an initial inspection on 6/25/25 where youth in care were interviewed and a collateral inspection at the administrative office on 6/25/25 to collect documentation related to the allegations, staffing, and client compatibility. A collateral inspection was conducted on 7/8/25 where five staff were interviewed. The allegation related to room compatibility is related to C1 and C2 (see LIC811 dated 7/17/25) sharing a bedroom and due to the age difference of six years, youth may not have been best compatible. When conducting interviews with the agency staff and youth in care, it was determined that the agency considers UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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: SUMMITVIEW CHILD & FAMILY SERVICES - LOTUSFACILITY NUMBER: VISIT DATE: 07/17/2025

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


state: CA

summary: Complaint Investigation - Unsubstantiated - 1 allegation

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Narrative:
During confidential interviews with youth, youth denied obtaining marijuana or vaping devices from the other named staff persons. When interviewed, staff denied they contributed marijuana and vaping devices to youth in care. Investigation failed to show any staff that could corroborate any staff providing marijuana or vaping devices to youth in care. As a result of the investigation and interviews conducted, the allegation that staff are providing marijuana to youth in care is UNSUBSTANTIATED at this time meaning the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted and documents were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced complaint inspection on 7/23/25 at 1: PM and met with Haley Randle, Director of Youth Residential Programs to discuss the allegation. LPA Hill informed NAME that the investigation included an initial inspection on 6/25/25 and collateral inspections on 6/25/25, 7/8/25, and 7/17/25 where clients and staff were interviewed and documents were collected. The allegation that staff gave minors marijuana while in care is related to an allegation that S1, S2, S3, S4, S5, and S6 supplied marijuana to C1, C2, and C3 (see LIC811 dated 7/23/25) while in care. This agency cross reported the same information for another facility on May 21, 2025. During an internal investigation, S1 admitted to allowing youth to use their vaping device and S1 was dismissed from their employment with the facility. S2 was also implicated during the internal investigation but dismissed for other reasons. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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: SUMMITVIEW CHILD & FAMILY SERVICES - LOTUSFACILITY NUMBER: VISIT DATE: 07/23/2025

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

report_type: Complaint Investigation

complaint_status: unsubstantiated


summary: Complaint Investigation - Unsubstantiated

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Narrative:
currently enrolled: Facility Roster, Needs and Services Plan and Privilege/Restrictions, emails from the facility staff to C1's County Social Worker (CSW) and LPA Hill, and an LIC500. On 7/28/ LPA Stidman received documentation of six children's face sheet, weight record, and admission agreement. Confidential interviews were conducted with 11 individuals on 7/25/25. 10 out of 11 interviews reported there was no smoking of marijuana at the facility. Based on LPA interviews 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. An exit interview was conducted, and a copy of this report was provided to Anna Gleason, CEO.

Investigation Findings:
13Licensing Program Analyst (LPA) Jean Stidman conducted an unannounced complaint inspection with the above facility on 10/9/25 at 1pm and met with Anna Gleason, CEO. The purpose of the inspection was to deliver complaint findings for the above allegations of staff allows minor to smoke marijuana inside the facility. On 7/17/ Licensing Program Analyst (LPA) Tamara Hill conducted an initial complaint inspection and met with Haley Randle, Director of Youth Residential Programs. LPA Hill conducted a physical plant inspection inside and out and met with facility staff to obtain documentation about staff and clients. LPA Hill informed the agency that this complaint needs further investigation at this time and that it may take up to 90 days to complete the investigation. The agency was informed that LPA Jean Stidman will be conducting the investigation. During the course of the investigation, the following documents were gathered and reviewed. On 7/17/ Licensing Program Analyst (LPA) Tamara Hill obtained the following documents for the six children UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jean Stidman 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: SUMMITVIEW CHILD & FAMILY SERVICES - LOTUSFACILITY NUMBER: VISIT DATE: 10/09/2025

met_with: Anna Gleason, CEO


summary: Facility Evaluation

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Narrative:
Licensing Program Analysts (LPAs) Tamara Hill and Mary Shelton made an unannounced annual inspection on 10/15/21 at 2: PM and met with Jose Navarette, STRTP Administrator, who assisted with the inspection. LPAs Hill and Shelton conducted a walk-through of the facility inside and out. There were no clients present during the inspection due to school and company barbecue happening at their school location. LPAs observed three dual occupancy client bedrooms and two bathrooms during the inspection. LPAs Hill and Shelton inspected and/or reviewed the following: Postings of facility license, Personal Rights Poster were appropriately posted Disinfectants/Cleaning solutions were inaccessible and locked as required Refrigerator Temperature was at or below 45 degrees F and Freezer Temperature at or below 0 degrees. There were multiple refrigerators and freezers on the premises that were well stocked. Nonperishable Foods for one week and fresh perishable for foods two days minimum were present Menu was present and posted Working telephone was present Carbon monoxide detectors and Smoke Detectors were functioning First Aid Kit was present but missing tweezers Common Room (living room) was available as was a separate room for relaxing and activities Dining area with enough seating for clients in care was present and in good condition Medication was centrally stored, locked/inaccessible LPAs did not observe a staff office as the agency believes that the staff should be present with the clients and not in the office doing administrative work when clients are present. All relative documentation is locked and inaccessible. Staff utilize a laptop to conduct daily record updates. Hot Water was between 105 -120 degree F Fire Extinguisher was observed to be last inspected on 6/3/ Toilets, wash basin, bath and shower fixtures appeared to be in good repair, no leaks and delivering hot water. LPAs observed there to be hand soap and paper towels available in the bathrooms and kitchen area. Laundry Facilities were available and LPAs observed posted assigned washing days for clients. Bedrooms appeared to be clean and organized with required linen and furnishings Motor Vehicle was not observed as the staff had taken the facility vehicle to pick up clients from company activity at Golden Plaza location. Facility appeared to be free of vermin and other pests as required. LPAs observed no citations during the physical plant inspection and no citations were issued. Exit interview conducted and documentation provided to the facility.

report_type: Facility Evaluation

visit_type: Annual

met_with: Abigail Nelson, STRTP Administrator


summary: Facility Evaluation

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Narrative:
Licensing Program Analysts (LPAs) Tamara Hill and Mary Shelton made an unannounced annual continuation inspection on 10/27/21 at 10: AM to the Non Public School location and met with Haley Randle, Director of Youth Residential Programs. The purpose of the visit was to continue the annual inspection started on 10/15/21 and interview clients and review client and staff documents. The facility did inform LPAs that all of their client and staff files are electronic and did work on providing LPAs access to the electronic databases. While LPAs waited for the access to review documentation, LPAs interviewed clients. LPAs spend the entire time at the agency interviewing clients and did not review staff or client documents. LPA Hill informed the agency that in order to conclude the annual inspection, it would take another inspection date on another day in order to conduct the file reviews necessary to complete the annual review for the facility. LPA reminded the agency that the visit must be unannounced. Exit interviewed conducted and document was provided. Hard copy signature was obtained via email as most the staff had already left or were leaving for the day.

visit_type: Case Management


summary: Facility Evaluation

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Narrative:
On Tuesday, May 12th, 2026, Licensing Program Analyst (LPA) Brittany Crass, arrived to the Administrative Office for a Case Management inspection for a self reported incident regarding a medication bottle getting grabbed by a client during a medication count. The 24 hour report for this incident that occurred on 5/4, was received by the Department late, on 5/7. LPA interviewed the Program Director, Haley Randle, who stated it is not typical protocol for staff to count medications in front of youth. The Program Director stated a new protocol which clearly states this is currently in progress and will be sent out to Lead Staff once finalized. This staff member (S1) will receive corrective action due to already being told verbally not to count medications in front of clients. No citations have been issued. This concludes this Case Management. Exit interview conducted with Haley Randle. A copy of this report and appeal rights were given.

met_with: Program Director, Haley Randle


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Narrative:
not communicating with authorized representative about incidents that lead to C1 missing appointment(s) until C1 was discharged from the facility. When interviewed, the authorized representative stated that the communication received was after C1 had already left the facility and that it was that C1 had an orthodontic appointment that had to be rescheduled twice due to behaviors. Authorized representative states that they had conducted two Child and Family Team (CFT) meetings while C1 was in the facility but that this was never brought up or discussed during those meetings. Authorized representative states that had this information been shared prior to discharge, the authorized representative could have made additional visits to the facility to assist in the transport to the necessary appointment(s) or stabilization of C1's placement prior to C1 being displaced. When LPA Hill interviewed agency staff, LPA Hill learned that there is no specific documentation or policy related to appointments made or cancelled for clients. Since this complaint investigation, they have now implemented procedures for documenting appointments made, reasons for cancellation when necessary, and notifications to placing agencies. As a result of the investigation, documents obtained and interviews conducted, the allegation that staff did not communicate with minor's responsible party [about the missed appointments] is SUBSTANTIATED meaning that the "preponderance of the evidence" standard has been met. Facility was cited for violation of Reporting Requirements, 80061(f) as the facility is required to make report(s) to the client's authorized representative of incidents, including but not limited to any unusual incident which threatens the physical or emotional health or safety of any client. LPA Hill observed that the facility did not provide C1's authorized representative information including the need to cancel medical, dental, and vision appointments as a result of behaviors. Exit interview conducted and documentation provided. requirement that the facility obtain a written medical assessment of clients admitted "prior to or within 30 calendar days following [their] acceptance". Complaint also alleges that C1 was not taken or provided access to dental or vision services. When reviewing the documentation related to C1, there is documentation that a physical was completed, by the placing agency, the week prior to placement. Related to dental services, it is documented that C1 had two appointments for orthodontia care but those appointments were cancelled due to unsafe behaviors. There is no documentation related to vision services being provided but the regulations do not speak to time frames for this to be conducted and C1 was in the facility for a month. As a result of the investigation, documents received, and interviews conducted the allegation that the facility did not ensure that C1 attended scheduled appointments is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Documentation was provided to the facility along with appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 7/20/23 at 1: PM and met with Jose Navarrete, Residential Manager to discuss the complaint allegations. LPA Hill informed Mr. Navarrete that the complaint inspection included an initial complaint inspection at the facility on 5/12/23. Interviews were conducted with reporting party, authorized representative, and administrator. LPA Hill also obtained communications between the agency and C1's (see LIC811 dated 7/20/23) authorized representative. LPA Hill obtained agency's internal daily communications related to C1 and their stay at the facility. LPA Hill received C1's placement paperwork, medication and other medical-related documentation, Needs and Services Plan, and incident reports. The allegation that staff did not communicate with minor's authorized representative is related to the agency SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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: SUMMITVIEW CHILD AND FAMILY SERVICES - AGAPEFACILITY NUMBER: VISIT DATE: 07/20/2023

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

met_with: Jose Navarrete, Residential Manager


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Narrative:
LPA Hill interviewed three youth and the administrator about the air conditioning unit being in disrepair and the comfortable environment for the youth. During interviews, it was indicated that the facility did contact an outside vendor to service the unit once it was noted on 8/9/23 that it was not functioning. The vendor came to the facility on 8/14/23 and 8/15/23, repairing it, but it stopped functioning again within 48 hours. The same vendor was asked to return to the facility on 8/17/23 and determined that a part needed to be replaced, but that it would take a few days for the part to come in. Final repair of the air condition unit was conducted on 8/22/23. During the time that the air conditioning unit was not functioning properly, the agency did supply the facility with an industrial-sized swamp cooler and fans for the youths' rooms to use during this time. The youth were offered to relocate to the administrative offices during this time but declined this option as they preferred to be in the facility where their bed and belongings were at. In addition, the agency provided LPA Hill with an invoice indicating annual maintenance with the same vendor dated July 13, 2022. Interviews conducted with staff and youth, indicated that while it was hot with the air conditioning unit not functioning, the agency did accommodate youth as best as possible by providing fans and an industrial-sized portable air conditioning unit in the facility until the necessary repairs could be completed. In addition, the agency offered to relocate youth temporarily to the administrative offices until the unit could be repaired but the youth opted to stay in the facility instead. As a result of the information obtained, documentation provided, and interviews conducted, the allegation that the facility air conditioning unit is in disrepair and that staff are not providing a comfortable environment for minors is UNSUBSTANTIATED meaning the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred as the agency made attempts to get a vendor to the facility for repair of the air conditioning unit and did attempt to make youth more comfortable by relocating youth to the agency's administrative offices while waiting for the unit to be repaired. Exit interview conducted and documents were provided to Ms. Randle.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 1/31/24 at 2: PM and met with Haley Randle, Director of Youth Residential Programs to discuss the findings for this complaint investigation. LPA Hill informed Ms. Randle that the complaint investigation included an initial physical plant inspection at the facility on 8/23/23 where it was observed that the facility was cool, air conditioning was working, and that the facility was neat and clean during the inspection. LPA Hill obtained documentation related to the air conditioning issue at the facility, including messages and discussions between staff about the excessive heat in the facility. LPA Hill also obtained a copies of invoices related to services conducted on 8/14/23 and 8/15/23 by an outside vendor. When the air conditioning unit stopped working a day later, the vendor returned to the facility, 8/17/23 and informed the agency that additional repairs were needed. The invoice indicates that the vendor finally completed the repairs for the air conditioning unit on 8/22/23. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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: SUMMITVIEW CHILD AND FAMILY SERVICES - AGAPEFACILITY NUMBER: VISIT DATE: 01/31/2024


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
the agency's school site, the explicit conversation about the male genitalia continued with S2 and with other youth present. This resulted in another youth knowing what photo was, without having seen the photo. During confidential interviews, it was indicated to be common knowledge for S1 to talk about inappropriate topics while in the classroom with youth present. As a result of the investigation conducted and confidential interviews conducted, the allegation that staff exposed minor to photos of nude adults is SUBSTANTIATED at this time, meaning the "preponderance of the evidence" standard has been met. The facility was cited for violation of Short Term Residential Therapeutic Programs, Interim Licensing Standards, Version 5, Section 87072(a) Personal Rights as youth have the right to be free from physical, sexual, emotional, or other abuse...given the photograph was that of male genitalia, this is a violation of those rights. Exit interview was conducted with Ms. Randle and documentation, along with appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 2/8/24 at 12: PM and met with Haley Randle, Director of Youth Residential Programs to discuss the complaint finding for the allegation noted. LPA Hill informed Ms. Randle that the investigation included an initial inspection on 10/6/23 where documentation was gathered. Investigation was conducted by the Department's Investigations Branch, specifically Investigator Melissa Weaver. Included in the investigation were interviews with C1 (see LIC811 dated 2/8/24), C2, S1, S2 and in collaboration with the El Dorado County Sheriff's Office. In addition, photos related to this allegation were obtained from Summitview Child and Family Services. The allegation is related to an incident where S1 showed an inappropriate picture of male genitalia to C1. Confidential interviews indicated that S1 did show these photos to youth and when S1 and youth arrived at SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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: SUMMITVIEW CHILD AND FAMILY SERVICES - AGAPEFACILITY NUMBER: VISIT DATE: 02/08/2024

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

complaint_status: SUBSTANTIATED


facility_name: SUMMITVIEW CHILD AND FAMILY SERVICES - AGAPE

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Narrative:
Investigation showed that maintenance was alerted to a possible incontinent issue in one of the facilities with youths beds prompting an agency-wide inspection which included all facilities operated by the Summitview Child & Family Agency. As a result of this inspection, mattresses were replaced if they were identified as soiled, stained, or showing signs of wear. It was alleged that one of the youth had removed the mattress cover after having an accident without telling staff so a new cover was not placed on the bed to prevent the soiling of the mattress. Staff interviewed indicated that the agency did an inspection of all the facility beds throughout the agency and replaced multiple mattresses throughout their facilities including the youth(s) who were identified as having incontinence issues. As a result of the investigation and interviews conducted, the allegation that youth was not provided with a mattress in good condition is SUBSTANTIATED at this time meaning the "preponderance of the evidence" standard has been met. The facility was cited for Short Term Residential Therapeutic Program, Interim Licensing Standards Section 87088(c)(1) Fixtures, Furniture, Equipment, and Supplies as the licensee is to provide and make readily available to each child an individual bed maintained in good repair; equipped with good springs and a clean mattress and investigation showed that one or more youth had been sleeping on a mattress that was soiled or mattresses that were identified as soiled or in need of being replaced as they did not meet this standard. Exit interview was conducted with Ms. Randle and documentation, including personal rights were provided. odor present as a result of the youths' incontinent issues, staff were cleaning the youths' rooms, doing the youths' laundry daily, and working with both youths on this issue in private so as to rid the facility of the smell. Interviews indicated that while it was difficult due to youths' behaviors of hiding clothes or not wanting to tell staff when there was an issue when youths' first arrived at the facility, staff tried. None of the staff and clients interviewed felt that staff were neglectful or dismissive of the issue and did take the youths' health and cleanliness issues seriously. As a result of this, while there was a smell that lasted in the house for about a month, the staff were working with youths in care to overcome the issues for a clean and safe environment for all in the facility. As a result of the investigation and interviews conducted, the allegations that licensee did not properly address minor's incontinence needs and did not ensure that the facility was kept odor free are UNSUBSTANTIATED at this time meaning that the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. The allegation that a youth is engaging in a relationship with an adult is related to a youth talking with an adult male while at the facility via a tablet furnished by Summitview Child and Family Services. During interviews, when it was discovered that youth was initiating conversations with this adult male. Subsequently, the tablet was removed and cleaned by the agency's technology department followed by firewalls being installed to prevent further contact with this individual. While the agency cannot prohibit calls due to youth's personal rights, the agency did discuss this further during youth's Child and Family Team meetings and is no longer a concern. As a result of the investigation and interviews conducted, the allegation that youth is engaging in a relationship with an adult is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with Ms. Randle and documents provided, including personal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 2/8/24 at 12: PM and met with Haley Randle, Director of Youth Residential Programs to discuss the complaint allegation. LPA Hill informed Ms. Randle that the investigation included an initial physical plant inspection at the facility on 10/20/23 with a collateral inspection conducted at the administrative offices for Summitview Child and Family Services as well. Subsequent collateral inspections to interview staff and clients were conducted on 12/15/23 and 1/31/24 where eight youth and seven staff were interviewed in total. The allegation that the licensee did not provide minor with a mattress in good condition is related to one or more mattresses being soiled due to an incontinent issue with one of the youths in care. During an agency initiated inspection conducted in October 2023, it was noted by agency staff that there were mattresses showing signs of wear and/or stained/soiled and the agency replaced identified mattresses for youth in care. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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: SUMMITVIEW CHILD & FAMILY SERVICES - SUGAR PINEFACILITY NUMBER: VISIT DATE: 02/08/2024

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


raw_content:
Narrative:
medical condition. Some of the recommendations on the documentation include the need to make lifestyle changes, including a healthy diet, an avoidance of processed foods and foods high in refined sugars and carbohydrates, and regular exercise. In addition, the paperwork indicates that the doctor recommended allowing youth to work with staff in selecting food choices for the shopping list and "snack box" at the facility that were conducive to youth's medical diagnosis. When interviewed, C1 indicated that initially the facility did not cater to C1's medical condition and options for snacks in the facility included inappropriate choices such as crackers and cups of noodles. C1 indicated that when C1's medical condition escalated and became emergent, then the facility began to work with youth on food choices, but this did not happen until C1 was about to leave and go home. Interviews conducted indicated that when the doctor provided suggestions on eating and logging food intake, they worked with youth to ensure doctor-recommended snack options were available and that food alternatives were offered including wheat bread versus white bread, wheat pasta versus bleached pasta, etc. LPA Hill requested copies of the menus for the facility from August 2023 to December 2023, that do not indicate alternatives as suggested or required by the doctor. The menu shows many food items specifically listed on the food avoidances list provided by the doctor. While substitutions may have been provided, there is no evidence that this happened as the menus provided do not indicate substitutes for items such as pancakes, sliders, sugary cereals, toast, rice, spaghetti, hamburgers (buns), baked potatoes, etc. to name a few. As a result of the information and documentation received, the allegation that the facility did not follow the doctor's orders is SUBSTANTIATED meaning the preponderance of evidence standard has been met. The facility was cited per Interim Licensing Standards, Section 87076(d) Food Services as food served shall meet special dietary needs...as recommended by a physician. The allegation that the facility leaves sharp objects accessible to clients in care is related to an incident where C1 had access to sharp objects and being able to access these sharp items without staff knowledge. LPA Hill observed an incident on or about 10/4/23, facility staff did not lock a staff drawer containing sharp items, including scissors, resulting in C1 accessing the drawer and getting some scissors without staff knowing. C1 then took the scissors into the bathroom during their shower time and cut their own hair without staff knowledge and without parental permission. While interviews indicated that the drawer was to remain locked, it was indicated that youth knew when staff neglected to lock the drawer as required. As a result of the information and documentation received, the allegation that the facility left sharp objects accessible to clients in care is SUBSTANTIATED meaning the preponderance of evidence standard has been met. The facility was cited per General Licensing Standards, Title Regulations, Section 80087(g)(1) Buildings and Grounds as dangerous items were not locked as required. The allegation that the facility is not conducting child and family team meetings (CFTs) as required is related to C1 not having the CFTs every 30 days as required by regulation. The reporting party states that while in care, the facility failed to conduct the required monthly Child and Family Team (CFT) meetings for this facility type of facility. During the investigation into these allegations, LPA Hill learned that C1 was initially placed into a different facility type with the same agency in April 2023. The licensee was informed that C1 required a Short Term Therapeutic Residential Program (STRTP) where the expectations and requirements were different. C1 was placed in the STRTP on 8/24/23, and a documented CFT meeting was conducted on 11/8/23. C1 was discharged from the facility 12/21/23. During this time, only one documented CFT was conducted, and no Needs and Services Plan was obtained for C1 from 8/24/23 to 12/21/23. As a result of the information and documentation received, the allegation that the facility is not conducting child and family team meetings (CFTs) as required is SUBSTANTIATED meaning the preponderance of evidence standard has been met. While regulations do not require a CFT every thirty days, the Needs and Services Plan are required to be updated every 30 days and shall consider recommendations of the child and family team, eluding to the requirement to have CFTs every 30 days. The facility was cited per the Interim Licensing Standards, Section 87068.3(b)(2) Modifications to the Needs and Services Plan. The allegation that the facility did not assist with discharge and aftercare services planning as required is related to C1 being discharged back to the care of their family with no aftercare services in place and no plan to continue to see youth until youth could get established with another provider for mental health services. The reporting party states that because C1 is a post adoption youth, they were informed that it was the family's responsibility to coordinate and look for services for C1 for ongoing mental health services after leaving placement because they lived so far away from the placement agency. When questioned, LPA Hill was informed that the therapist is responsible for postdischarge services for youth leaving care. When asked for proof of aftercare services coordination for C1, LPA Hill was informed that there were no aftercare services provided or coordinated for C1. Additional documentation provided shows there was a lack of communication with the Health Services Department within Summitview "on several things related to [C1's] health". As a result of the information and documentation received, the allegation that the facility did not assist with discharge and aftercare services planning as required is SUBSTANTIATED meaning the preponderance of evidence standard has been met. The facility was cited per the Interim Licensing Standards, Section 87089.1(d)(3) Mental Health as the facility shall ensure continuity of care, services, and treatment as a child moves from their short-term residential therapeutic program placement to home-based family care for at least six months postdischarge from a short-term residential therapeutic program. In this case, C1 went home without the required array of services as required. Exit interview was conducted with Ms. Randle and documentation was provided including appeal rights. indicated that they have asked for additional training related to good choices and getting C1 engaged in making healthy choices. C1 tends to refuse these services. Food shoppers were given healthy alternatives to purchase to have on hand for the house but cannot force youth to make those healthy choices. Regarding the allegation that the facility is threatening C1 with discharge is related to C1 needing to go to the emergency room due to their health condition and the facility informing the reporting party that if C1 were to go and be formally diagnosed with a medical condition that they could not handle or may not be able to accommodate, C1 would be discharged from the program. In speaking with the staff that regularly interacted with the reporting party and Chief Executive Officer, it was denied that C1 was ever threatened with discharge from the facility for diagnosis of this medical condition. The allegation that facility staff were discussing employment and/or discipline topics with youth in care is related to staff complaining about specific aspects of their employment with youth in care or where youth could hear these discussions. Staff were discussing topics such as not being paid enough to deal with youth, that staff are leaving their jobs to find employment that pays more, or being written up for things that youth do, and other personnel issues around youth in care. LPA Hill obtained proof of the facility's knowledge that at least one staff member was doing this via an email dated 10/19/23 to that staff person identifying that this is an issue when youth are present. In addition, there were multiple notices for staff about discussions in front of youth in care including 3/30/22, 8/17/23, 11/9/23 and 1/31/24. While this was happening at the agency, it was addressed, staff were counseled/reminded that this is not an acceptable practice. LPA Hill did not find additional personnel speaking about personnel issues around youth in care following the email reminder to not discuss personnel issues or other inappropriate topics in the facility. The allegation that staff did not appropriately intervene in adult/child interactions is related to an interaction that C1 had with outside medical personnel during a routine medical appointment. It was alleged that C1 reported that the interaction was a "deep conversation" with the medical personnel individual and may have been inappropriate as it was related to what drugs do to the brain. When interviewed, staff indicated that they would not always stop those conversations as youth benefit from hearing the same message from multiple individuals, not just the facility staff. Staff indicated that these messages go further when heard from multiple different sources. When interviewed, C1 indicated that staff accompanied C1 during the entire time of the appointments. During interviews, staff indicated that they would not intervene unless youth are having inappropriate conversations about the benefits of illicit drug use or how to obtain or use drugs. Staff indicated that the transport never reported an inappropriate conversation during a medical appointment, indicating that staff did not feel any conversations had been inappropriate. As a result of the investigation, interviews conducted, and documentation reviewed, the allegations that the facility did not meet the need of C1 as it relates to C1's health condition, the facility threatened to discharge C1, facility staff discussed employment and/or discipline topics with youth in care and facility staff did not appropriately intervene in adult/child interactions are all UNSUBSTANTIATED at this time meaning the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview was conducted with Ms. Randle and documentation, along with appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 3/21/24 at 10: AM and met with Haley Randle, Director of Youth Residential Programs to discuss complaint findings. LPA Hill explained the complaint allegations to Ms. Randle that investigation included an initial inspection to the facility on 11/8/23 and interviews with seven clients from and five staff, including the agency Chief Executive Officer (CEO) from 11/8/23 through 3/20/24. LPA Hill obtained documentation from the Director of Youth Residential Programs and CEO regarding C1 (see LIC811 dated 3/21/24). The allegation that the facility did not follow the doctor's orders is related to C1's medical condition needing specific food items and/or alternatives. When interviewed, the reporting party stated that the facility did not follow the doctor's orders in that they provided food choices in the home that were contrary to dietary recommendations based on C1's medical condition. In review of the documentation received from the facility, it was noted on medical paperwork that a care plan was developed on 10/20/23 to assist in managing C1's SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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: SUMMITVIEW CHILD & FAMILY SERVICES - SUGAR PINEFACILITY NUMBER: VISIT DATE: 03/21/2024

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


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Narrative:
When arriving at the nonpublic site, S1 and C1 got into S1's vehicle and C1 observed S1's vaping device in the vehicle. S1 admits that the vaping device was in plain sight in the vehicle but that they put the device away immediately upon getting into the vehicle but that C1 had already seen it. Confidential interviews indicate conflicting statements as to whether or not S1 allowed C1 to use their vaping device during the transport. As a result of the information obtained and interviews conducted, the allegation that staff allowed a youth to smoke in staff's personal vehicle is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. The allegation that staff disclosed personal information to youth is related to an alleged disclosure that S1 shared personal information about themselves to C1 that may have been inappropriate or triggering to youth in care. When interviewed, C1 disclosed that S1 shared a traumatic event that had happened to themselves and that this information and/or disclosure was triggering to C1 due to their own trauma. During an interview with S1, they denied that they shared more than peripheral information about themselves in an effort to demonstrate to youth that it is possible to overcome their circumstances. S1 denied sharing any traumatic information about themselves as they understand that personal stories can be triggering to youth in care and can take the focus off of youth in care. As a result of the information obtained and interviews conducted, the allegation that staff disclosed personal information to youth is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. The allegation that staff spoke inappropriately to youth is related to a disclosure made by C1 that S1 spoke to C1 about a romantic text between S1 and S2. During confidential interviews, both staff denied any romantic interest and/or text messages between themselves. C1 refused interview with LPA Hill and would not elaborate on any information to assist in the investigation. As a result of the information obtained and interviews conducted, the allegation that staff spoke inappropriately to youth is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with Ms. Randle and documentation was provided, along with appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 4/17/24 at 1: PM and met with Haley Randle, Director of Youth Residential Programs to discuss the findings of this complaint investigation. LPA Hill informed Ms. Randle that the complaint investigation included an initial inspection to the facility on 2/8/24 and collateral inspections were conducted 2/8/24, 3/21/24, and 4/5/24 to interview staff and clients in care. During the collateral inspections, LPA Hill interviewed three staff and one client. The allegation that staff allowed a youth to smoke in staff's personal vehicle is related to a transport of C1 conducted by S1 (see LIC811 dated 4/17/24) on 1/29/24. The incident involved S1 taking the agency van back to the school location to retrieve S1's personal vehicle that was left behind due to staff being need that day for transport from the agency's nonpublic school to the facility. S1 states that this was out of the normal for them and that normally they arrived at the facility to begin their shift. C1 asked S1 to go along for the ride and upon receiving approval from the administrator, S1 took C1 with them. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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: SUMMITVIEW CHILD & FAMILY SERVICES - SUGAR PINEFACILITY NUMBER: VISIT DATE: 04/17/2024

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


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Narrative:
in an effort to combat the pests, the facility staff and clients were also advised to wash all of the clothing, bedding, and maintain a clean the facility. While the facility did all of this, the bed bug issue persisted and the youth in the facility continued to complain about bed bug bites. Documentation shows that the facility became aware of the bed bug issues in the facility on 4/1/24 and began treatments including spraying the facility, washing youths' clothes, stripping of the beds and laundering of the clothing and bedding for the youth. Based on interviews with staff and clients, staff attempted to launder youths' clothing and bedding and this proved unsuccessful and the pests persisted. As of 4/12/24, the facility maintenance, in consultation with a local pest control, attempted to rid the facility of the pests by spraying the interior of the house with chemicals on a weekly basis as advised by the local pest control and advising all staff to pack up youths' belongings, including soft items, into bins once laundered but this did not resolve the issue. As of 5/6/24, documentation obtained from the facility indicates that the initial treatments were not successful and the agency hired a local pest control, Hangtown Pest Control, to conduct a more thorough treatment, including "three treatments over three weeks". This treatment required all clothing items to be washed and dried on hot settings and other items to be placed in large containers and stored until the treatment was complete. Beds were to be stripped daily and the rooms deep cleaned for the three weeks and all personal items could not be returned to the youths' bedrooms for the three weeks. The agency knew about the bed bug issue in the facility and attempted to address the issue in-house in April 2024 but they were not successful at combating this issue until hiring a professional pest control in May 2024 to render the services necessary, prolonging the treatment and presences of the pests in the facility. While the facility did not sit idle and ignore the pest issue, they did prolong treatment by attempting to address the pests in-house and not using a professional service as needed. As a result of this, the allegation that the facility did not address pests is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Ms. Randle and documentation was provided, including appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 5/24/24 at 1: PM and met with Haley Randle, Director of Youth Residential Programs to discuss the findings of the allegations as stated. LPA Hill informed Ms. Randle that the investigation included an initial physical plant inspection on 4/5/24. A collateral inspection at the agency was also conducted on 4/5/24 where interviews with four youth and one staff were conducted. An additional collateral inspection was conducted on 4/17/24 where LPA Hill obtained documentation related to pest control and an interview with maintenance was conducted. LPA Hill received documentation related to the treatment of the pests, bed bugs, that indicated the facility maintenance had collaborated with the local pest control on the best treatment option and the facility implemented periodic pest management as indicated. While maintenance staff were spraying the facility UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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: SUMMITVIEW CHILD & FAMILY SERVICES - SUGAR PINEFACILITY NUMBER: VISIT DATE: 05/24/2024

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


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Narrative:
This complaint investigation named S1 in addition to S2, S3, and S4 as providing vaping devices, including tobacco and marijuana, to youth in care. S1 was interviewed for the previous complaint investigation and S1 denied ever providing a vaping device to a youth in care. S1 made statements eluding to the agency not paying them enough to purchase vaping devices to give to youth in care. S1 did acknowledge that one youth (not connected to this investigation) saw their personal vaping device in their car during a transport one time and requested to "hit it" but S1 denied allowing youth to use the vape. S2, S3, and S4 were all interviewed and all staff denied supplying vaping devices to youth in care. S1 did not continue to work for the agency following the previous investigation due to reasons not solely related to the allegation. Law enforcement interviewed C1 and this is where additional staff were named (S2, S3, S4) and that disclosure indicated that they directly provided vapes, had direct knowledge about the vapes and who was supplying them, or were in collaboration with staff providing vapes to youth in care. C1 also disclosed that C4, and C2 and C3 (who do not live at this facility) all knew about the vapes and knew the staff named were providing vapes to youth in the agency. Following the complaint allegation, C1 did not return to the facility. When interviewed, S2, S3, and S4 all denied ever providing vaping devices to youth in care and denied knowing that youth were getting vaping devices from any staff working for the agency. Staff indicated that they thought youth were bringing in vapes when returning from home passes, from youth who attended public schools in the area, or when the youth residing in the facility interact with outside youth that come to the agency for therapy and groups in the afternoons. Staff stated that they thought the vapes were brought in by youth and subsequently passed to other youth in the agency and through the different facilities as this is what youth indicated when vaping devices were recovered. C2 and C3 were interviewed on 6/27/24 and neither could confirm that they paid staff or requested that staff provide vapes or that they saw a transaction of this nature. Both youth stated that they only heard rumors about this happening but had no direct proof or knowledge and no staff ever confirmed this directly to either youth. Both youth talked about S1 taking money from youth for snacks and bringing back snacks to youth but neither disclosed any information about S1 or any other staff providing vapes. C4 was interviewed in conjunction with the previous complaint investigation and they too denied knowing about, receiving, or seeing any staff provide vapes to youth in care. All youth confirmed that they heard about S1 providing vapes via rumors throughout the agency but none indicated that they had any proof. The allegation that staff threatened minors in care is related to the providing of the vapes and alleges that S1 threatened to get youth kicked out of the program if they told administrative staff or anyone about S1 providing the vaping devices. The interview conducted by law enforcement indicates that C1 denied being threatened by staff about the vaping devices but a subsequent interview of C1 conducted by C1's social worker indicated that C1 revealed they felt threatened and did not want to return to the agency as they felt that they would be retaliated upon or that C1 would be targeted as a snitch for making the report. No other youth confirmed any threats as they denied being involved with or receiving vaping devices. As a result of the interviews conducted and investigation completed the allegations that staff is providing smoke contraband to minors in care and that staff threatened minors in care are UNSUBSTANTIATED at this time meaning the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview was conducted with Ms. Gleason and documentation was provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 7/18/24 at 9: AM and met with Anna Gleason, Chief Executive Officer to discuss the findings of this complaint investigation. LPA Hill informed Ms. Gleason that the investigation included an initial inspection on 4/11/24 where documents related to staff and clients in care was obtained. This complaint investigation was referred to our Investigations Branch (IB) for further investigation where IB obtained police reports resulting from the cross report of these allegations. LPA Hill documented the Law Enforcement Interviews conducted with staff and youth interviewed. LPA Hill interviewed S1, S2, S3, S4, and youth C3 and C4 (see LIC811 dated 7/18/24) on 6/27/24. The allegation that staff is providing smoke contraband to minors in care was originally investigated via complaint dated 3/13/24 where only S1 was named as providing the smoke contraband to youth in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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: SUMMITVIEW CHILD & FAMILY SERVICES - SUGAR PINEFACILITY NUMBER: VISIT DATE: 07/18/2024

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

met_with: Anna Gleason, Chief Executive Officer


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Youth and staff interviews failed to identify any witnesses to the alleged hit. Further interviews with staff to whom the disclosure was made indicated that when C1 made this disclosure, C1 had no bruises or marks to indicate being hit. As a result of the information obtained, interviews conducted and documentation obtained, the allegation that C1 was hit by S1 is UNSUBSTANTIATED at this time meaning the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. The allegation that staff deny youth time away is related to staff not allowing youth to take space during the schooling hours at the facility. LPA Hill conducted confidential interviews with staff and youth present at the facility during schooling hours and it was revealed that the agency is temporarily providing educational services in the residential facility until their educational site, same as the administrative site, has completed their construction to allow youth to move back to this site for educational instruction. S1 and S2 indicated that on most days they are the primary staff responsible for educational services to youth in care as well as the supervision of youth during the schooling hours. Staff indicated that this facility is a tri-level facility and that having youth on different levels presents a challenge for supervision during the educational hours so they typically keep all youth in the lower level of the facility during schooling hours. Staff state they typically have five or six youth attending the educational services provided at this location with two to three staff present to supervise and assist. Staff interviews indicate they are responsible for supervision of youth during these hours, including maintaining visual of youth. While staff try to give youth options of taking space when feeling overwhelmed or agitated, it is restricted to direct line of sight of staff. Staff states that when the staffing allows for additional staffing at the facility during schooling hours they can accommodate walk-abouts or other services youth request. Confidential interviews with youth also indicated that they can walk outside if they want to take space or need a break as long as they remain in sight of staff supervising. As a result of the information obtained and interviews conducted, the allegation that staff deny youth time away is UNSUBSTANTIATED at this time meaning the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with Ms. Maglietta and documentation was provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint investigation inspection on 1/29/25 at 3: PM and met with Jessica Maglietta, Administrator, to discuss the findings of the complaint investigation related to the allegations stated. LPA Hill informed Ms. Maglietta that the complaint investigation included an initial inspection at the facility on 9/18/24 where the facility was inspected and interviews were conducted. LPA Hill also conducted a collateral inspection at the administrative office to collect client documents. Confidential interviews were conducted from 9/18/24 to 1/29/25 of direct care staff, administrative staff, and youth in care. The allegation that staff hit a minor in care is related to an alleged disclosure that S1 hit C1 (see LIC811 dated 1/29/25) on their arm some time in August 2024. During an interview conducted with C1, C1 alleges they, S1 and C1, were not within the camera's view at the facility so there would be no proof via camera footage. Confidential interviews were conducted with staff and youth identified as being present and/or witness to this incident. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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: SUMMITVIEW CHILD & FAMILY SERVICES - SUGAR PINEFACILITY NUMBER: VISIT DATE: 01/29/2025

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

met_with: Jessica Maglietta, Administrator


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Administrative staff indicated that while this is not explicitly stated in the personnel policies, it is discussed in staff meetings, and in other forums with staff from the time of initial employment throughout staffs employment with the agency. Confidential interviews with staff working at the facility, indicated they are aware of this policy and are aware of the expectation to adhere to the dress code polices due to the nature of the behaviors and histories of the youth in care. Confidential interviews with youth in care indicate that it was pointed out to S1 by youth shortly after S1 arrived at the facility for their shift. As a result of the investigation including interviews conducted and documentation obtained, the allegation that staff was inappropriately dressed is SUBSTANTIATED at this time meaning the "preponderance of the evidence" standard has been met. The facility was cited for violation of the STRTP Interim Licensing Standards, Section 87065(g)(1)(B) Personnel Requirements. Investigation showed that staff are to demonstrate knowledge, skills and abilities to engage and develop a rapport with children who have diverse backgrounds. S1 was not able to do this as S1 did not adhere to the same policies youth are required to adhere to, compromising their ability to develop that rapport. Exit interview was conducted with Ms. Gleason and documentation was provided to the facility including appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill conducted a complaint inspection on 2/25/25 at 3: PM and met with Anna Gleason, Chief Executive Officer, to provide findings for to the allegation stated. LPA Hill informed Ms. Gleason that the complaint investigation included an initial inspection at the facility on 11/21/24 where five youth and three staff were interviewed. Subsequent interviews of two staff were conducted on 1/24/25 as well as collection of documentation related to an electronic message exchange between S1 (see LIC811 dated 2/25/25) and Haley Randle, Director of Youth Residential Programs. The allegation about staff not being dressed appropriately is related to an allegation that S1 arrived for their shift at the facility on 11/13/24, not wearing an undergarment. While the facility does have a dress code policy for youths in care, the same policy does not exist for staff. However, administrative staff state it is an implied policy that staff adhere to the same requirements as youth, including the dress code. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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: SUMMITVIEW CHILD & FAMILY SERVICES - SUGAR PINEFACILITY NUMBER: VISIT DATE: 02/25/2025

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


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Narrative:
During LPA Hill's initial inspection at the facility, LPA Hill did observe youths' lunches that were being provided and they were sack lunches that had a sandwich, an apple, a granola bar, string cheese, and a bag of chips. Interviews with youth in care indicated that they are all given opportunities to pack their own lunches the night prior and these lunches are brought to the house where youth are attending educational services. Youth indicated that if they forget to pack their lunch, run out of time, or just do not want to, the overnight staff packs youths' lunches for them and it typically includes the items listed. While the lunches meet regulatory requirements, youth indicated they are tired of the "same thing" every day and would prefer other things, including hot lunches. When interviewing staff, they indicated this is not possible due to staffing as the youth are split in different houses for educational programs. Staff indicated that they will be transitioning to the nonpublic school site as soon as the remodel and approvals are granted and they do not have the facilities for preparing hot meals for youth there either. Youth indicated there are not alternatives provided for youth, except a different kind of sandwich. As a result of the investigation related to the staff not providing adequate food service to minor(s) in care, the complaint is UNSUBSTANTIATED at this time meaning the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. LPA Hill did issue an advisory about providing alternative meals for youth in care or involving youth in the planning of meals. See LIC9102-TA.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill conducted a complaint inspection on 2/25/25 at 3: PM and met with Anna Gleason, Chief Executive Officer, to provide findings for to the allegation stated. LPA Hill informed Ms. Geason that the complaint investigation included an initial inspection at the facility on 11/12/24 where eight youth and three staff were interviewed. The allegation that staff did not provide adequate food service to minor(s) in care is related to the youths' lunches they are provided daily. Interviews included youth attending the educational services at the facility, not just the youth who reside in the facility. Youth indicated that they were displeased with the choices of food being provided for their lunches, indicating that it is the same every day. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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: SUMMITVIEW CHILD & FAMILY SERVICES - SUGAR PINEFACILITY NUMBER: VISIT DATE: 02/25/2025

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


raw_content:
Narrative:
While C1 left the facility on an unauthorized absence and upon apprehension by law enforcement, was taken for further assessment. Youth were told by staff that C1 would not be returning and to move on and not speak about the events. C1 returned to the facility prior to youth waking up in the morning and without warning to youth in care. Other youth in care reported that they did not feel safe with C1 returning to the facility due to the magnitude of the events that took place. Following such events happening in the facility, youth typically have access to an on-call therapist, via teleservices but youth in care expressed that there was a need to be able to process the events of the incident as a group but this was not offered or conducted. Confidential interviews indicated that youth did not feel that staff could keep them safe due to the seriousness of the incident with C1 returning to the facility without preparing youth in care and without providing youth the ability to process the incident in a trauma informed manner. Additional confidential interviews further indicated that the seriousness of this incident scared both, youth and staff, and brought about past traumatic experiences that youth would have benefitted from having a therapist present to assist in processing the events immediately following the incident. Confidential interviews indicated that youth and staff alike expressed that having a therapist come to the facility when an incident of this magnitude occurs would allow the youth to process as a group and assist youth in feeling safe, heard, and supported. It was further discussed that telling youth to stop talking about the event and not giving youth an avenue to discuss the events of the incidents in a safe and supportive space, is not trauma informed and does not allow youth to process their past traumatic experiences brought up by incidents of this nature. Confidential interviews further indicated that having the therapist available via a video chat is not the same as the in-person collaboration and youth tend to not engage in the video collaboration offered. As a result of the investigation conducted, including confidential interviews, the allegation that staff did not provide a safe environment for youth in care is SUBSTANTIATED at this time meaning that the "preponderance of the evidence" standard has been met. The facility was cited for violation of Short Term Residential Therapeutic Programs, Interim Licensing Standards, Section 87078.2(a)(3) Trauma-Informed Interventions and Treatment Practices as staff are required to understand the types of trauma experienced by children..., how to provide care and supervision that is trauma informed..., and how to reduce risk of re-traumatization. The youth were not provided the trauma informed care necessary following a serious incident that would have allowed youth to process their trauma experiences and move forward in a trauma informed manner.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced complaint inspection on 5/1/25 at 9: AM and met with Haley Randle, Director of Youth Residential Programs to discuss the findings of the allegation as noted. LPA Hill informed Ms. Randle that the complaint inspection included an initial inspection to the facility on 1/29/25 where two youth were interviewed. LPA Hill interviewed three youth on 3/27/25 and conducted interviews with staff from 3/26/25 through 4/18/25. Three youth refused to be interviewed during the initial inspection on 1/29/25. The allegation that staff did not provide a safe environment for minors is related to an incident that occurred at the facility on 1/21/25, where C1 (see LIC811 dated 5/1/25) got upset at other youth in care and made threats to staff and youth. C1 caused substantial property damage trying to get at youth in care causing staff and youth to barricade themselves in rooms to keep C1 from going after staff and youth. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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: SUMMITVIEW CHILD & FAMILY SERVICES - SUGAR PINEFACILITY NUMBER: VISIT DATE: 05/01/2025

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


raw_content:
Narrative:
note also indicates that if C1 were to call, "make sure no one knows it's me" indicating that S1 knew this was against agency policy to be in contact with clients outside of their shift. Another note (date unknown as it is not dated or signed) believed to have been written by C1 followed by a note written by S1 at the bottom of the same page. While C1 denied writing this letter, acknowledges that the writing at the bottom is S1's writing. S1's writing on this note details wanting to kiss and hold C1. This note also states C1 should not tell anybody and to be patient, "one day we'll be together". S2 and S3 called S1 into the administrative office to discuss the allegation and while S1 acknowledged it was their handwriting on at least one of the notes, denied the note(s) being for C1. S1 denied having any inappropriate conversations or interactions with C1. S1 was dismissed from the agency upon discovery of the correspondence. When contacted as part of the investigation, S1 declined to provide a statement regarding the allegation. As a result of the investigation, interviews conducted, and documentation obtained, the allegation that staff had inappropriate contact with minor in care is SUBSTANTIATED at this time meaning the "preponderance of the evidence" standard has been met. Facility was cited for violation of Short Term Residential Therapeutic Program, Interim Licensing Standards, Section 87072(c)(16) Personal Rights as youth in care have the right to be free of...emotional...abuse including...exploitation...or coercion. S1 was secretly corresponding with a youth in care in an effort to exploit C1's vulnerability. Exit interview conducted with Ms. Randle, and documents provided along with appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced complaint inspection on 6/10/25 at 10: AM and met with Haley Randle, Director of Youth Residential Programs, to discuss the findings of the allegation as stated. LPA Hill informed Ms. Randle that the complaint investigation included an initial inspection at the facility on 5/29/25 with a collateral inspection conducted on the same date to collect documentation related to S1 and C1 (see LIC811 dated DATE) and spoke to administrative staff about the allegations. LPA Hill also obtained letters written by S1 to/for C1 while working in the facility. LPA Hill contacted S1 on 6/4/25 tried to schedule an interview but S1 declined. LPA Hill interviewed C1 on 6/5/25. The allegation that staff had inappropriate contact with a minor in care is related to S1's hand written communication(s) with C1. One note appeared to be written by S1 and it is believed to be intended for C1, there are no names on the letter but is signed "love" and gives S1's phone number followed by "XOXO". This SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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: SUMMITVIEW CHILD & FAMILY SERVICES - SUGAR PINEFACILITY NUMBER: VISIT DATE: 06/10/2025

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


facility_name: SUMMITVIEW CHILD & FAMILY SERVICES - SUGAR PINE

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an announced Pre-Licensing Inspection on 6/27/24 at 8: AM and met with Haley Randle, Director of Youth Residential Programs. LPA Hill toured the facility inside and out and observed the following in this home: * Main floor of the home has the kitchen area, dining area with seating for eight, living room area, one half restroom, staff room where chemicals and client files are to be stored. The dining room has a cabinet where the medications are to be stored and this cabinet has a two lock system for all medications and first aid supplies to be stored in. * Second floor of the home has two dual occupancy rooms and two single occupancy rooms that have all of the required furniture. Additional furniture, bedding and other needed supplies are coming with the relocation of the youth for their current location. This floor also has one restroom centrally located and accessible to youth and the other restrooms is in the master bedroom. These are full restrooms, including showers, sinks, toilets, and other necessary storage. Since the cabinets in the restrooms cannot lock, there will be nothing stored in these restrooms that cannot otherwise be accessible to youth in care. * Basement floor of the home is where the youth will be doing schooling, therapy or other activities in the home. This floor has a restroom as well as storage closets that will not be accessible to youth. There are desks in the garage that will be placed in this space for therapists and/or youth to use for schooling. * Linens and other excess items will be stored in the garage area. Laundry area is in the garage. * Outdoor area of the facility was observed to have rubbish from trees and log/wood piles that all need to be removed. Ms. Randle informed maintenance that this needs to be attended to immediately. LPA Hill also observed tree rounds in the yard and suggested possibly a seating area be designed for youth to sit outside on using these rounds but if the facility is not going to utilize them then they need to be removed. * Smoke detectors were functioning and carbon monoxide detectors are on every floor. LPA Hill and Ms. Randle discussed the submission of the Program Statement and Plan of Operation by 7/1/24. LPA Hill observed that the facility is ready for licensure and will provide the recommendation as needed to the management. End of document.

visit_type: Prelicensing


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced case management inspection on 8/16/24 at 11: AM and met with Jose Navarrete, Residential Manager. LPA Hill conducted the inspection on this date as a follow up regarding an incident report dated 8/14/24 where C1 (see LIC811 dated 8/16/24) went on a 1:1 visit with a staff member at the agency and where youth gained access to unauthorized medications. When interviewed staff states that they watched C1 enter the restroom during their outing but did not clear the restroom prior to allowing youth to enter. In the restroom were several first aid supplies and a bottle of pills marked "pain killers" but staff did not think to clear the restroom prior to allowing youth to enter. Staff has only been working with the youth and agency for two months and was provided subsequent training immediately after this incident about clearing public restrooms or asking youth to wait until they return to the facility if clearing is not possible. LPA Hill provided the documentation and advisory note (TA) to Mr. Navarrete.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 8/23/24 at 12:40 and met with Joy Rose, Learning Coach/MHS II. LPA Hill made the case management inspection to discuss an incident dated 8/19/24 that allegedly took placed at this house during the facility's schooling hours. While the youth (C1, see LIC811 dated 8/23/24) does not reside in this house, C1 attends schooling and group hours at this location. LPA Hill spoke with S1 who spent time with C1 outside of the classroom on 8/19/24 and did participate in one of C1's coping mechanisms while C1 was struggling. Youth was not available during the case management inspection today due to another incident that took place that removed youth from the agency. End of documentation.

met_with: Joy Rose, Learning Coach/MHS II


facility_name: HATHAWAY-SYCAMORES CHILD AND FAMILY SERVICES

summary: Facility Evaluation

raw_content:
Narrative:
On 03/04/2022 at 9am, Licensing Program Analyst (LPA) Bernice Karnsrithong arrived at the facility for the purpose of conducting a pre-licensing inspection. LPA met with Administrator, Daisy Delgado who granted tour and access to the facility. LPA Karnsrithong conducted the health and safety risk assessment upon arriving at the facility. There are currently no clients in the facility. There are no bodies of water in the premises. The facility is located in a residential neighborhood. The entire campus is fenced in and gated. The Administrative Office is located in the front part of the campus. Covid- Health and Safety checks are conducted in the front reception area. The facility is to provide care and supervision for male youth ages eleven (11) to seventeen (17) and non-minor dependents with a capacity up to sixteen (16) clients. LPA Karnsrithong has observed the following during the Pre-Licensing Inspection: The facility composes of three (3) cottages: Baldwin, Swartzott and Hutter. Baldwin Cottage: This cottage has four (4) bedrooms, three (3) bathrooms, a staff office, dining room, kitchen, laundry area, living room and laundry room. It has one (1) storage rooms to store supplies for the cottage. The utility shut-off valve for this cottage is at the back. There is a separate laundry room in this cottage equipped with storage cabinets and individual lockers. It has a working washer and dryer unit. Bedrooms: Each bedroom is equipped with a twin-size bed with linens, a cabinet with a locker, adequate lighting, a desk and a chair. There is a window with screens that is in good condition. One bedroom next to the Living Room is currently being used by the other STRTP for one (1) client. It has one bed with mattress and linens, a desk, a cabinet with a locker, and adequate lighting. (Page 1 of 3) Bathrooms: One full size bathroom is being used by staff. It has a toilet, sink, and shower all in good working condition. There is one bedroom that has a half bathroom with toilet and sink. All bathrooms are clean and water temperature are in safe range. There are cabinets to be used for storage in all bathrooms. Kitchen/Dining Area: The kitchen and dining area is next to the Living Room. It has a table and chairs to be used for meals and for studying. It has a full-size kitchen with a four (4) gas stove oven with a hood range, a microwave, dishwasher, and toaster. There is sufficient cabinet space for non-perishable food items and dry goods. There is a French door style refrigerator in the kitchen. There is fire extinguisher in the kitchen area. Living Room: The living room is next to the Kitchen/Dining Area. It is equipped with a television, a coffee table, couches, a media center with books and a video game console. Licensing postings and children's rights are posted in the Living Room area. There is fire extinguisher in the living room. Swartzott Cottage: This cottage has four (4) double bedrooms, two (2) bathrooms, living room and kitchen. The utility shut-off valve for this cottage is at the back. There is no laundry room for this cottage. Bedrooms: All bedrooms are equipped with twin size mattress, with linens, two (2) cabinets and one (1) desk and a chair. There is a window with screens that is in good condition Bathrooms: There are two (2) full sized bathrooms in this cottage. It is equipped with toilet, sink, and shower all in good working condition. All water temperatures are in safe range. There are cabinets to be used for storage in all bathrooms. The showers in this cottage have shower doors instead of shower curtains. Kitchen: The kitchen is equipped with a four (4) burner gas stove, a microwave, French door style refrigerator, toilet, sink, and dishwasher. There is adequate cabinet space for kitchen items and food supplies. There is a working fire extinguisher in the kitchen area. All food preparation area is clean and well maintained. Living Room: The living room is next to the kitchen. It is equipped with a television cabinet, coffee table, media center, and couches. There is a fire extinguisher in the Living Room area. (Page 2 of 3) Hutter Cottage: This cottage has four (4) bedrooms, two (2) bathrooms, kitchen, laundry room and living room. The utility shut-off valve for this cottage is out in the front. There is a laundry room in this cottage that has a separate door entrance outside. It has a working washer and dryer. Bedrooms: All bedrooms are equipped with twin size mattress, with linens, two (2) cabinets and one (1) desk and a chair. There is a window with screens that is in good condition. Bathrooms: There are two (2) full sized bathrooms in this cottage. It is equipped with toilet, sink, and shower all in good working condition. All water temperatures are in safe range. There are cabinets to be used for storage in all bathrooms. The showers in this cottage have shower doors instead of shower curtains. Kitchen: There is a fire extinguisher in the kitchen area to be used in case of emergencies. It is equipped with a gas stove, a microwave, French door style refrigerator, toilet, sink, and dishwasher. There is adequate cabinet space for kitchen items and food supplies. There is a working fire extinguisher in the kitchen area. There is trash can with a tight fitted lid in the kitchen. Living Room: The living room is next to the kitchen. It is equipped with a television cabinet, coffee table, media center, and couches. There is a fire extinguisher in the Living Room area. All clients have access to outdoor space. The campus has patio seating and tables throughout. It has a outdoor garden next to Hutter Cottage, a recreational hall, a basketball court, exercise equipment, swing set that is all securely bolted in to the ground. There is a pergola with patio furniture next to the other STRTP campus. The facility has an Emergency Disaster Plan in place. All staff are regularly trained for emergency safety quarterly. Each cottage has its own basic first aid supplies. Most medical and first aid supplies and equipment are stored in the nurse's office. The facility has its on-site nurse that provides basic medical care and administers medication for clients as needed. All medication is centrally stored in the nurses office. Medication logs for clients are stored in the nurse office and available for review and audit if needed. LPA Karnsrithong reviewed ten (10) staff files. All staff assigned to this facility have criminal background clearance. There are no deficiencies cited at this time. Exit interview was conducted with Administrator, Daisy Delgado. A copy of this report will be provided to the facility. (Page 3 of 3)

met_with: Daisy Delgado, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 12/29/2022, Licensing Program Analyst (LPA) Bernice Karnsrithong arrived at the facility at 11am for the purpose of case management verifying cottages being used by the Sycamores Short Term Residential Therapeutic Program (STRTP) South Campus. Health and safety risk assessment was conducted upon arriving at the facility. LPA Karnsrithong met with Daisy Delgado, Director of Residential Programs who granted tour and access to the facility. This facility is licensed to provide care and supervision to up to sixteen (16) children ages six (6) to seventeen (17) ambulatory only and to Non-Minor Dependents (NMD). The current census for the facility during the visit is ten (10). The facility is composed of two (2) cottages that are being utilized by clients, Hutter and Swartzott. Hutter Cottage has four (4) bedrooms and two (2) bathrooms. Each bedroom has two (2) twin sized beds, closet space, a desk and adequate lighting. Each bathroom has its own toilet and shower. This cottage also has its own laundry room and a kitchen/dining and living room area. The current census for Hutter Cottage is five (5). Swartzott Cottage has four (4) bedrooms and two (2) bathrooms. Each bedroom has two (2) twin sized beds, closet space, a desk and adequate lighting. Each bathroom has its own toilet and shower. This cottage also has its own laundry room and a kitchen/dining and living room area. The current census for Swartzott Cottage is five (5) during the visit. Currently Family Cottages and Baldwin Cottage is being used for isolation for COVID-19. Baldwin Cottage is also being used for storage. The isolation areas are labeled "Red Zone" when it is in use. The facility has updated its program statement to reflect the changes regarding the facility's designated isolation area and storage.