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Narrative:
while in care. Specifically, it was reported that C1 turned up the TV because staff shift change was happening and C1 could not hear the TV. S1, allegedly, became upset and turned off the TV. C1 became angry and turned the TV back on. It was then reported that S1 got in C1's face, telling C1 to leave the TV alone. C1 requested for S1 to "get out of (C1's) face" and shoved S1 when S1 did not remove self from C1 personal space. There was a power struggle between C1 and S1 as C1 pushed S1 and S1 attempted to redirect C1. They were witnessed to have ended up wrestling near the couch and landed on the floor of the facility living room. Allegedly, S1 proceeded to push C1 down the hallway in an effort to put C1 in C1's room. Several corroborating statements confirm S1 was raising S1's voice while attempting to get C1 to go to C1's room. Confidential witnesses state S1 attempted to restrain C1 during the altercation. Several witnesses corroborate seeing S1 put hands on C1 in an attempt to redirect and restrain C1 from potentially hitting S1. Other witnesses corroborate hearing C1 yell, several times, "Get your hands off me!" to S1. During the investigation, S1 confirmed S1 put hands on C1, stating S1 attempted to put C1 in a child pose, one-arm restraint, which S1 states S1 is trained to conduct. S1 also confirmed S1 tried to physically turn C1 around to redirect C1 to C1's room, however, was only able to "maintain control of (C1's) forearms". Corroborating statements confirm that eventually S1 and C1 released their holds on each other and C1 retreated to C1's room. Another confidential witness confirms seeing S1 restrain C1's arms as C1 yelled, "Get your hands off me!" and both of them struggling with each other like they were going to fall on the floor during the incident. Based on confidential interviews, information gathered, and review of the facility's program statement which states restraints are not to be used on clients, the allegation that S1 engaged in a physical altercation with C1 while in care is SUBSTANTIATED because the preponderance of evidence standard has been met for the allegation. This poses a potential health, safety, or personal rights risk to clients in care. The facility is being cited under Interim Licensing Standards (ILS) section 87095, General Provisions. An exit interview was conducted and a copy of this report, LIC 811, and appeal rights, were provided to FM Ayla Losoya, for signature. Signed report will be placed in facility file.

Investigation Findings:
13On April 20, 2022, at 11: AM, Licensing Program Analyst (LPA) Carmen Escobar made contact with short term residential therapeutic program (STRTP) facility manager (FM), Ayla Losoya. LPA Escobar conducted a facility risk assessment with FM and proceeded to continue with the facility inspection to issue the investigative finding for the above allegation. During the investigation, LPA requested documents from client 1 (C1's), client 2 (C2's), and client 3 (C3's) files including placement agreements, copy of C1's needs and service plan, and special incident reports involving C1. LPA also obtained a copy of the STRTP client roster and staff roster. LPA Escobar conducted interviews with three staff members, C1's county social worker, C1, C2 and C3. LPA Escobar conducted an in-person inspection of the STRTP on 02/28/22 at 2: PM, no health or safety concerns were observed at the time. It was alleged that on or around 02/28/22, S1 engaged in a physical altercation with C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Carmen Escobar LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: PENNACLE FOUNDATION INCFACILITY NUMBER: VISIT DATE: 04/20/2022

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

met_with: Facility Manager (FM)-Ayla Losoya


state: CA

facility_name: PENNACLE FOUNDATION INC

summary: Complaint Investigation - Unsubstantiated - 1 allegation

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Narrative:
the pills were vitamins and there was also nothing mentioned by authorized representative that the pills were vitamins. Even though C1 advised S2 the pills were vitamins, S2 could not confirm this information and for C1's safety, flushed the vitamins down the toilet. S2 was unaware of a proper way to dispose of drugs/pills and later participated in staff training that provided instructions on proper disposal of medication/pills/drugs and also proper documentation. Another witness observed the actual flushing of the vitamins and became upset with S2 at time of incident. Other witnesses corroborate that even though they did not witness the flushing of the vitamins, they were made aware by upper administration/management, that this incident had occurred prior to the staff training that was completed. Based on confidential interviews and information gathered, the allegation that S2 flushed C1's vitamins while in care is SUBSTANTIATED because the preponderance of evidence standard has been met for the allegation. This poses a potential health, safety, or personal rights risk to clients in care. The facility is being cited under Interim Licensing Standards section 87072, Personal Rights. An exit interview was conducted and a copy of this report, LIC 811, and appeal rights, were provided to FM, Candice Caldwell, for signature. Original signed reports will be placed in facility file. Specifically, it was reported that C1 has been denied access to C1's phone book. Several witnesses corroborate this is not true and C1 has constant access to any phone numbers C1 might need, including CSW's, county representatives, legal entities, etc. It was also detailed that S1 gets in C1's face and yells at C1, however, no details of this were reported. It was further reported that S1 will say things such as, "If (C2) sticks (C2's) thumb up your (C1's) butt, you're gay right?" While two witnesses corroborate these two allegations, all other witnesses state this has never been observed and S1 does not yell at clients or says things as indicated on report. Several other witnesses state these incidents have never been reported to them during C1's time at the facility. It was also reported S1 refuses to make C1 food, however, all witnesses corroborate that while several staff, including S1, do not cook for the clients in the facility at times, staff will order food or pick up fast food for clients. While S1 states S1 does not cook and does not like to cook, S1 states S1 will buy clients fast food or will order food for clients, including C1. Several other witnesses corroborate this information, some even stating they would rather eat fast food than eat food cooked by staff. Again, other witnesses advise this has not been reported to them during C1's time at the facility. It was then detailed that S1 threatened to make C1 food with a dirty plate or food that is contaminated. S1 denies this allegation stating C1 can be unhygienic and S1 will have to remind C1 to not touch C1's private parts and then touch plates in the kitchen, or food in the kitchen, as it will contaminate items with unhygienic germs. Another witness denies this occurring. Several witnesses corroborated this incident, advising S1 was not threatening C1, but was advising of proper hygiene when eating and preparing food. This incident was also not shared with other parties and, therefore, not witnessed. It was further detailed that C1 does not have access to TV or WiFi in the facility, causing C1 to be bored. Several staff deny this allegation and advise the TV and internet are always available to C1 as long as C1 has completed chores and has not lost privileges. While a witness maintains this continues to occur, several other witnesses deny this allegation, stating the TV is always on and staff usually allow clients to use the WiFi when requested. Finally, it was also reported that C1 has not been enrolled in school, however, the facility provided documentation of the ongoing enrollment process which has taken longer than usual, but not due to lack of effort by the facility, simply issues with school district in regards to C1's educational needs and behavioral issues. While a witness maintains this was the case initially, the facility has now been able to enroll C1 into school. S1 denies all allegations related to S1 and C1. While another witness maintains the allegations are true, several witnesses deny ever observing these allegations occur. Based on interviews conducted, the allegations that S1 denied C1 access to phone book, S1 yells at C1 while in care, S1 makes inappropriate comments towards C1, S1 refused to make food for C1 while in care, S1 threatened C1 while in care, staff deny C1 access to activities while in care, and C1 is not enrolled into school while in care may have occurred, however, they are not supported or proven by evidence. The allegations are, therefore, UNSUBSTANTIATED. There are no deficiencies to be cited. Exit interview was conducted and a copy of this report and appeal rights, were provided to FM for original signature. Report will be put into facility file.

Investigation Findings:
13On September 30, 2022, at 10: AM, Licensing Program Analyst (LPA) Carmen Escobar arrived at the short term residential therapeutic program (STRTP) facility and met with facility manager (FM), Candice Caldwell. LPA Escobar conducted a facility risk assessment with FM and proceeded to continue with the facility inspection to issue the investigative finding for the above allegation. During the investigation, LPA requested documents from client 1 (C1's), client 2 (C2's), and client 3 (C3's) files including placement agreements, copy of C1's needs and service plan, and special incident reports involving C1. LPA also obtained a copy of the STRTP client roster and staff roster. LPA Escobar conducted interviews with three staff members, C1, C2, C3, and C1's county social worker (CSW). LPA Escobar conducted an in-person inspection of the STRTP on 03/09/22 at 10: AM, no health or safety concerns were observed at the time. It was alleged that on or around 03/01/22, S2 flushed C1's vitamins while in care. Specifically, it was reported that when C1 arrived to the facility for placement, S2 flushed C1's vitamins down the toilet. Several witnesses corroborate this. S2 stated vitamins were flushed because they were not in a container indicating SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Carmen Escobar LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: PENNACLE FOUNDATION INCFACILITY NUMBER: VISIT DATE: 09/30/2022

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

report_type: Complaint Investigation

met_with: Facility Manager-Candice Caldwell

complaint_status: unsubstantiated


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Narrative:
not updated, were missing signatures, and were missing explanations. LPA confirmed this information upon review of client medication records for months of September and October 2022. Additionally, the reason for missed medication was not provided on some entries. Staff corroborate they were unaware of some of the required information needed on medication log records. The facility is being cited for violation of the Interim Licensing Standards section 87070(13)(G)(1), Children's Records. Based on confidential interviews, information gathered, and LPA's own observation and review of client medication logs, the allegation staff do not adequately maintain minor's medication records is SUBSTANTIATED because the preponderance of evidence standard has been met for the allegation. This poses a potential health, safety, or personal rights risk to clients in care. The facility is being cited the Interim Licensing Standards cited above. An exit interview was conducted and a copy of this report, LIC 811, and appeal rights, were emailed to Mr. Zachary for signature. Original signed reports will be placed in facility file. reported C1 has limited clean clothing in C1's closet and all the clothes were also on the floor of C1's room or in the dirty laundry hamper. Lastly, it was also reported that the space for therapy is in the garage where the temperature gets very high. While a witnesses maintains all the allegation details are correct, all other witnesses corroborate that the details of each allegation are untrue. Witnesses corroborate that while there may have been an old food menu on the fridge on at least one occasion, the menu is usually updated, however, clients request to eat out or would rather order food other than the food being cooked. LPA observed clients have scheduled laundry days and as long as clients are capable of doing their laundry the washer and dryer are available to clients for laundry needs. C1 has not wanted to do C1's laundry and keeps C1's room messy, regardless of being asked to pick up C1's clothes. Staff have also done C1's laundry on several occasions, as C1 does not complete C1's chores. Based on interviews conducted, the allegations that minors are not provided a food menu, C1's laundry needs are not being met, minors are not being provided a comfortable temperature, may have occurred, however, they are not supported or proven by evidence. The allegations are, therefore, UNSUBSTANTIATED. There are no deficiencies to be cited. An exit interview was conducted and a copy of this report, LIC 811, and appeal rights, were provided to FM, Zachary Williams, for original signature. Signed report will be placed in facility file.

Investigation Findings:
13On November 18, 2022, at 10: AM, Licensing Program Analyst (LPA) Carmen Escobar arrived at the Short-Term Residential Therapy Program (STRTP) facility and met with Facility Manager, Mr. William Zachary. LPA Escobar conducted a facility risk assessment interview with FM and proceeded to issue the investigative finding for the above allegations. During the investigation, LPA requested documents from client 1 (C1's) file including placement agreement, copy of C1's needs and service plan from time of allegation, special incident reports involving C1 and facility roster at time of allegation. LPA Escobar conducted interviews with staff 1 (S1), staff 2 (S2), staff 3 (S3), C1, client 2 (C2), client 3 (C3), C1's county social worker (CSW) and another involved party. The initial ten-day inspection to initiate the complaint investigation was completed by LPA Escobar at the facility on 09/14/21 at 12: PM, no health or safety concerns were observed. It was alleged that on or around 09/09/21, staff do not adequately maintain minor's medication records. Specifically, it was reported that the medication documentation logs are not in compliance. The logs were SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Carmen Escobar LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: PENNACLE FOUNDATION INCFACILITY NUMBER: VISIT DATE: 11/18/2022

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

met_with: Facility manager-Wiliam Zachary


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Narrative:
On October 27, 2022, Community Care Licensing (CCL) received a complaint alleging that staff mishandled a minor while in care. Regarding the allegation that LFM mishandled C1 while in care, a confidential interview stated that C1 was held by LFM to prevent C1 from hurting self and others. Confidential interview continued stating that during the incident LFM embraced C1 by placing both arms around C1. Confidential interview stated that law enforcement arrived to respond to C1's behaviors and spoke to C1 and LFM about the incident. LPA Urena obtained a 24-hour notice and a Law Enforcement Report dated 10/26/22 that states "C1 was moving so aggressively that LFM laid on C1 for approximately two minutes while trying to calm the client and de-escalate the situation". Another confidential interview stated that clients have expressed concerns about being mishandled by staff while in care but denied that staff were intentionally mistreating clients in care and added that staff are trained on how to respond to emergency situations. It was discovered that during the process of responding to C1's behaviors LFM did use a one-person restraint as a method of de-escalation. Based on confidential interviews, and record review the preponderance of evidence standard has been met, and the allegation that LFM mishandled C1 while in care, is supported and proven by evidence. The facility is cited for violation of Interim Licensing Standards (ILS) version four Section 87072(c)(11) PERSONAL RIGHTS. Exit interview was conducted. A copy of this report, along with LIC D, LIC 811, and appeal rights were explained and will be emailed to Pennacle Foundation Inc. STRTP Administrator Carolyn Ruffin. In regard to the allegation that LFM choked C1 while in care, A confidential interview denied that LFM choked C1 rather LFM was responding to C1 breaking windows at the facility resulting in no injury to C1's neck. Another confidential interview stated that staff only place hands-on clients as a last resort and for safety purposes only. Confidential interview denied that staff maltreat clients in care. Other confidential interviews denied witnessing LFM choking C1 while in care. Another confidential interview stated that C1 did not report concerns to CSW about staff maltreatment at the facility. Confidential interview further reported that CSW did not have concerns about the placement. C1 could not be reached for comment. LPA received inconsistent information about whether or not LFM choked C1 while in care. Based on confidential interviews, and record review the allegation that LFM choked C1 while in care, may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Administrator Carolyn Ruffin.

Investigation Findings:
13On April 27, 2023, at 12: PM, Licensing Program Analyst (LPA) Cynthia Urena conducted an unannounced visit at Pennacle Foundation Inc. Short Term Residential Therapeutic Program (STRTP) to deliver the finding of the above stated allegation. LPA was met by Adminsitrator Carolyn Ruffin. LPA Carmen Escobar conducted an inspection of the facility on November 3, 2022, at 10: AM and no immediate deficiencies were observed. On April 11, 2023, LPA Urena continued with the investigation at the STRTP and conducted interviews with a Lead Facility Manager (LFM), Administrator (ADM) and two staff members (S1, S2,). LPA attempted to interview two clients (C2, C3) however, both clients declined to be interviewed. Client #1 (C1) could not be reached for an interview due to an absence without leave (AWOL) status. Additionally, LPA interviewed a County Social Worker (CSW). SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: PENNACLE FOUNDATION INCFACILITY NUMBER: VISIT DATE: 04/27/2023

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: Administrator Carolyn Ruffin


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Narrative:
On November 17, 2022, Community Care Licensing (CCL) received a complaint alleging that staff choked a minor while in care, staff handled minor in an inappropriate manner, and that minor engaged in a physical altercation with another minor while in care. Regarding the allegations that staff choked C1 while in care and that staff mishandled C1 while in care, confidential interviews denied that staff choked and mishandled C1 while in care. Confidential interviews further stated that staff do intervene during client-on-client physical altercations but deny client mistreatment during the process. Other confidential interviews stated that C1 wanted to go back to county of origin and expressed to staff that C1 would inform school staff the C1 did not feel safe at current placement. Another confidential interview declined to provide any comments due to C1's short stay at the facility, and C1 could not be reached for an interview. LPA received inconsistent information regarding the allegations. Regarding the allegation that C1 engaged in a physical altercation with another client, a confidential interview stated that there was a fight that resulted in C1 being body slammed by another client in care. Confidential interview continued stating not being sure what occurred but maintained that C1 wanted to return to county of origin and was willing to make false allegations to get relocated. Other confidential interviews denied witnessing an altercation between C1 and another client. LPA received inconsistent information regarding the allegation. Based on confidential interviews, and record review the allegation that staff choked C1 while in care, staff handled C1 in an inappropriate manner, and that C1 engaged in a physical altercation with another minor while in care, may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted. A copy of this report, along with LIC D, LIC 811, and appeal rights were explained and will be emailed to Pennacle Foundation Inc. STRTP Lead Facility Manager, William Zachary

Investigation Findings:
13On April 27, 2023, at 1: PM, Licensing Program Analyst (LPA) Cynthia Urena conducted an unannounced visit at Pennacle Foundation Inc. Short Term Residential Therapeutic Program (STRTP) to deliver the finding of the above stated allegations. LPA was met by Lead Facility Manager, William Zachary. LPA Carmen Escobar conducted an inspection of the facility on November 3, 2022, at 9: AM and no immediate deficiencies were observed. On April 11, 2022, LPA Urena continued with the investigation at the STRTP and continued an interview with a Lead Facility Manager (LFM). In addition, LPA Urena conducted interviews Administrator (ADM) and four staff members (S1, S2, S3, S4). LPA attempted to interview two clients (C2, C3) however, both clients declined to be interviewed. Client #1 (C1) could not be reached for an interview due to an absence without leave (AWOL) status. Additionally, LPA interviewed a County Social Worker (CSW). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: PENNACLE FOUNDATION INCFACILITY NUMBER: VISIT DATE: 04/27/2023

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

met_with: Lead Facility Manager, William Zachary


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Narrative:
Regarding the allegation that staff do not prevent an inappropriate interaction between minors while in care, confidential interviews disclosed that staff did not prevent an inappropriate interaction between clients which resulted in an allegation of sexual abuse between clients (C1 and C2). Information gathered from confidential interviews stated that C1 indicated being inappropriately touched by another client in the home (C2). Other confidential interviews deny that there was any inappropriate interaction between clients. Information gathered from interviews stated that staff go over boundaries and respecting personal space with clients in care. Further information gathered revealed that when a client expressed that there was a possibility that they were inappropriately touched, staff sought medical attention for the client, reported the incident to law enforcement, and made proper room arrangements so that clients in care did not have to share a room with the alleged perpetrator. Based on interviews and confidential information obtained during this investigation, LPA received inconsistent information regarding the allegation. The allegation staff do not prevent an inappropriate interaction between minors while in care, may have occurred, however it is not supported, or proven by evidence. Confidential interviews could not confirm or dispute these allegations; Therefore, the allegations are unsubstantiated at this time. Exit interview conducted, appeal rights were discussed, and provided. A copy of this report was provided to Lead Facility Manager, William Zachary.

Investigation Findings:
13On May 17, 2023 at 11: AM, Licensing Program Analyst (LPA),Cynthia Urena, met with Pennacle Foundation Inc., Short Term Residential Therapeutic Program (STRTP), Lead Facility Manager, William Zachary, to deliver the findings for the above stated allegation. LPA Carmen Escobar conducted an inspection of the facility on October 26, 2022, at approximately 11:05 am and no immediate deficiencies were observed. The investigation included interviews with three staff (S1, S2, and S3) and two out of two foster youth (C1 and C2). Two County Social Workers (CSW's) did not respond to LPA's request for an interview, after multiple attempts, and therefore were not interviewed. In addition, county records and facility records were reviewed. On October 18, 2022, Community Care Licensing (CCL) received an allegation alleging that staff do not prevent an inappropriate interaction between minors while in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: PENNACLE FOUNDATION INCFACILITY NUMBER: VISIT DATE: 05/17/2023

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


raw_content:
Narrative:
Specifically, it was reported that C1 did not have access to the home and would wander the neighborhood. Regarding the allegation that staff do not ensure C1 has access into the home while in care, information gathered stated that C1 was not given access to the facility and would go around neighboring homes stating that they were locked out of the facility. Additional information detailed that C1 would have to wait for staff to return from picking up other clients in the home and would not have access to the home while waiting. Other confidential interviews denied that staff does not ensure that minors have access into the home and that staff is present to let clients into the facility. There were limited details as to what staff members did not allow C1 access into the home or when clients in care were denied access to the home while in care. Regarding the allegation that staff do not prevent minor from wandering while in care, confidential interviews confirmed that clients in care wander off without any staff supervision, specifically C1. Further details gathered from interviews stated that staff would take away or hide shoes from clients in care to prevent clients from wandering or being absent from care. Other confidential interviews denied that staff do not prevent minors from wandering while in care. Additional details gathered that some clients in care were allowed to go on walks that did not require staff supervision and would not return on time or would be absent from care. Confidential interviews detailed that some clients were chronically absent from care and would leave the facility but then come back. Staff was unable to force clients to stay in the facility to prevent being absent from care but would use other methods such as redirecting and encouraging clients to stay in the facility. Furthermore, when unable to prevent clients from being absent from care staff would contact law enforcement to report clients being absent from care. Based on interviews and confidential information obtained during the course of this investigation, LPA received inconsistent information regarding the allegations that staff do not ensure that minor has access into the home while in care and staff do not prevent minor from wandering while in care, may have occurred, however is not supported, or proven by evidence. Therefore, the above allegations are unsubstantiated at this time. Exit interview conducted, appeal rights were discussed, and provided. A copy of this report along with, Confidential Names List, provided to Lead Facility Manager, William Zachary.

Investigation Findings:
13On May 17, 2023 at 11: AM, Licensing Program Analyst (LPA), Cynthia Urena, met with Pennacle Foundation Inc., Short Term Residential Therapeutic Program (STRTP), Lead Facility Manager, William Zachary, to deliver the findings for the above stated allegation. LPA Carmen Escobar conducted an inspection of the facility on October 26, 2022, at approximately 11:50 am and no immediate deficiencies were observed. The investigation included interviews with three staff (S1, S2, and S3), and three out of four clients (C1, C2, C3, C4). One of four clients declined to be interviewed. In addition, county records and facility records were reviewed. On October 19, 2022, Community Care Licensing (CCL) received an allegation alleging that staff do not ensure that minor has access into the home while in care and staff do not prevent minor from wandering while in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: PENNACLE FOUNDATION INCFACILITY NUMBER: VISIT DATE: 05/17/2023

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


raw_content:
Narrative:
On November 18, 2022, Community Care Licensing (CCL) received a complaint alleging that staff choked minor while in care, and that staff handled minor in an inappropriate manner. During investigation, a confidential interview stated that S1 hurt C1 while in care. Confidential interview stated that on one occasion S1 used S1's foot and placed it on C1's head to hold C1 down. Confidential interview stated that other staff and clients were present during this incident, however confidential interview could not identify the names of staff or clients who witnessed the incident. Other confidential interviews denied that S1 choked C1 or inappropriately handled C1 while in care. Confidential interviews stated that it was difficult for C1 to communicate with peers and with staff while in care which resulted in C1's aggressive acts towards self and others. Confidential interviews stated that C1 wanted to go back to county of origin and C1 was going to do what C1 could do to be removed from the facility. Confidential interviews maintained that C1 was not choked or mishandled while in care and added that C1 provided false statements with the purpose of being relocated. LPA received inconsistent information about whether or not C1 was choked or handled inappropriately by S1 while in care. Based on confidential interviews, and record review the allegation that S1 choked C1 while in care, and that S1 handled C1 in an inappropriate manner, may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Lead Facility Manager, William Zachary.

Investigation Findings:
13On May 17, 2023 at 11: AM, Licensing Program Analyst (LPA) Cynthia Urena conducted an unannounced visit at Pennacle Foundation Inc. ,Short Term Residential Therapeutic Program (STRTP) to deliver the finding of the above stated allegations. LPA was met by Lead Facility Manager, William Zachary. On November 18, 2022, at 4: PM, LPA Carmen Escobar conducted an inspection of the facility, and no immediate deficiencies were observed. LPA Urena interviewed Lead Facility Manager (LFM), Administrator (ADM), Facility Social Worker (FSW) and a staff member (S1). LPA Tinoco interviewed a client #1 (C1). LPA Urena attempted to interview client #2 (C2) and client #3 (C3) however, C2, C3 declined to be interviewed. Additionally, a County Social Worker (CSW), and a Supervising County Social Worker could not be reached for comment after multiple attempts made by LPA Urena for an interview. LPA Urena was informed that CSW and Supervisor are no longer employed with the department. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: PENNACLE FOUNDATION INCFACILITY NUMBER: VISIT DATE: 05/17/2023

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


raw_content:
Narrative:
On November 29, 2022, Community Care Licensing (CCL) received a complaint alleging that staff provided supervision to minor(s) in care while under the influence and that staff yelled at minors while in care. It was reported to CCL that S1 and S2 appeared to be under the influence and yelling at clients at a holiday event that resulted in C1 expressing feeling unsafe. During investigation, a confidential interview further stated that C1 was transported back to the facility by someone else other than S1 and S2 due to C1's safety concerns. Other confidential interviews denied that S1 and S2 were under the influence at the event and denied that S1 and S2 were yelling at clients rather it was clients yelling at each other and using profanity while inside the facility vehicle due to a fight for a front seat spot. Another confidential interview disclosed having no knowledge regarding the allegations nor being familiar with S1 or S2. LPA received inconsistent information about whether or not S1, S2 were under the influence or yelling at minors while in care and there were no other known witnesses. A CSW and a Supervisor could not be reached for comment. Based on confidential interviews, and record review the allegation that S1, S2 provided supervision to minor(s) in care while under the influence and that S1, S2 yelled at minors while in care, may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Lead Facility Manager, William Zachary.

Investigation Findings:
On May 17, 2023 at 12: PM, Licensing Program Analyst (LPA) Cynthia Urena conducted an unannounced visit at Pennacle Foundation Inc., Short Term Residential Therapeutic Program (STRTP) to deliver the finding of the above stated allegations. LPA was met by Lead Facility Manager, William Zachary. On November 29, 2022, at 10: AM LPA Carmen Escobar conducted an inspection of the facility, and no immediate deficiencies were observed. LPA Urena conducted interviews with Lead Facility Manager (LFM), Administrator (ADM), two staff members involved (S1, S2) and a Court Appointed Special Advocate (CASA). LPA Tinoco interviewed client #1 (C1). LPA Urena attempted to interview client #2 (C2) however, C2 declined to be interviewed. Additionally, a County Social Worker (CSW), and a supervising County Social Worker could not be reached for comment after multiple attempts made by LPA Urena for an interview. LPA Urena was informed that CSW and Supervisor are no longer employed with the department. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: PENNACLE FOUNDATION INCFACILITY NUMBER: VISIT DATE: 05/17/2023

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


raw_content:
Narrative:
On November 29, 2022, Community Care Licensing (CCL) received a complaint alleging that staff did not prevent minor from physically assaulting other minor while in care, and that staff do not provide a safe environment for minor(s) in care. During investigation, confidential interviews revealed that an altercation between C1 and C2 did occur while in care and it resulted in C1 obtaining medical care for an injury. Confidential interviews denied that the altercation was a result of lack of supervision and added that C2's behaviors against C1 were unexpected. Another confidential interview stated that C1 did not feel safe while in care and that other altercations between C1 and C2 occurred in the past. Confidential interview continued stating that C1 was not provided with medical attention for the injury sustained and that C1 was hurt often while in care. Confidential interviews stated that C1 was involved in multiple fights with other clients in care with the hopes of being removed from placement. Confidential interviews continued stating that staff respond to altercations among clients by separating clients and that staff ensure the safety of all clients in placement daily. C2, CSW and CSW's Supervisor could not be reached for comment regarding the above allegations. LPA received inconsistent information about whether or not staff prevented C2 from physically assaulting C1 while in care or if staff were providing a safe environment for C1 while in care. There were no other known witnesses to the allegations. Based on confidential interviews, and record review the allegation that staff did not prevent C2 from physically assaulting C1 while in care, and that staff do not provide a safe environment for C1 in care, may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Lead Facility Manager, William Zachary.

Investigation Findings:
13On May 17, 2023 at 12: PM, Licensing Program Analyst (LPA) Cynthia Urena conducted an unannounced visit at Pennacle Foundation Inc., Short Term Residential Therapeutic Program (STRTP) to deliver the finding of the above stated allegations. LPA was met by Lead Facility Manager, William Zachary. On December 6, 2022, at 11: AM, LPA Carmen Escobar conducted an inspection of the facility, and no immediate deficiencies were observed. LPA Escobar interviewed two staff members (S1, S2). LPA Urena interviewed Lead Facility Manager (LFM) and Facility Social Worker (FSW). LPA Tinoco interviewed client #1 (C1). LPA Urena attempted to interview client #2 (C2) however, C2 declined to be interviewed. Additionally, a County Social Worker (CSW), and a Supervising County Social Worker could not be reached for comment after multiple attempts made by LPA Urena for an interview. LPA Urena was informed that CSW and Supervisor are no longer employed with the department. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: PENNACLE FOUNDATION INCFACILITY NUMBER: VISIT DATE: 05/17/2023

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


raw_content:
Narrative:
It was reported that LFM threatened C1 while in care because of a situation involving C1, and neighbors that resulted in a facility vehicle being vandalized by the neighbors. Confidential interview stated that LFM made threats against the safety of C1 and C1 called law enforcement due to safety concerns. Another confidential interview denied aggressive acts towards C1 and stated that although a car was vandalized LFM did not make threats or mishandled C1 inappropriate manner. Confidential interview further stated that LFM chose not to become involved in a situation involving C1 and neighbors that resulted in C1 becoming upset and acting aggressive towards LFM. Another confidential interview denied witnessing LFM mishandling C1 while in care. Confidential interview further stated that clients have the ability to report all concerns or issues involving staff, however, nothing was reported. It was reported that C1 had a history of being untruthful and that C1 had behaviors that were difficult to manage while in care. LPA received inconsistent information about whether or not LFM handled C1 in an appropriate manner or if LFM threatened C1 while in care and there were no other known witnesses to the allegations. Additionally, a CSW could not be reached for comment. Based on confidential interviews, and record review the allegation that LFM handled C1 in an inappropriate manner, and that LFM threatened C1 in care, may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Lead Facility Manager, William Zachary.

Investigation Findings:
13On May 17, 2023, at 12: PM, Licensing Program Analyst (LPA) Cynthia Urena conducted an unannounced visit at Pennacle Foundation Inc., Short Term Residential Therapeutic Program (STRTP) to deliver the finding of the above stated allegations. LPA was met by Lead Facility Manager, William Zachary. LPA Carmen Escobar conducted an inspection of the facility on December 13, 2022, at 3: PM and no immediate deficiencies were observed. LPA Urena conducted interviews with a Lead Facility Manager (LFM), Administrator (ADM), Facility Social Worker (FSW) and client #1 (C1). LPA attempted to interview two clients (C2, C3) however, both clients declined to be interviewed. Additionally, a County Social Worker (CSW) could not be reached after multiple attempts made by LPA Urena for an interview. On December 7, 2022, Community Care Licensing (CCL) received a complaint alleging that staff handled minor in an inappropriate manner, and that staff threatened minor in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: PENNACLE FOUNDATION INCFACILITY NUMBER: VISIT DATE: 05/17/2023

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


raw_content:
Narrative:
On January 31, 2023, Community Care Licensing (CCL) received complaints alleging that minor consumed alcohol and smoked marijuana on the premises, minor sustained injuries while in care, minor engaged in physical altercations while in care, and that staff did not intervene while minor was engaged in physical altercations. Regarding the allegations that C1 consumed alcohol and smoked marijuana on the premises, confidential interviews reported that C1 had a history of substance use prior to placement and was found in possession of drug paraphernalia on multiple occasions while in care. Confidential interviews further reported that it is unknown where C1 obtained marijuana or alcohol while in care but added that C1 left the facility without permission frequently. Confidential interviews reported that staff confiscated and discarded marijuana and other drug paraphernalia from C1 resulting in aggressive behaviors towards staff and ultimately C1's termination from placement. LPA received reports to support that C1 was in possession of marijuana and other drug paraphernalia while in care. However, C1 could not be reached for comment regarding the allegation that C1 consumed alcohol and marijuana on the premises. Regarding the allegations that minor sustained injuries while in care, minor engaged in physical altercations while in care and that staff did not intervene while minor was engaged in physical altercations, SI Jackson received information that C1 was involved in an incident resulting in injuries. It was reported that during an outing with staff and peers C1 required medical attention due to an incident resulting in a face injury from playing with another youth in care. It was further reported that during this incident staff were present and provided C1 with the medical attention and follow-up care needed. Other confidential interviews reported that C1 engaged in multiple fights with peers where C1 was the aggressor. Confidential interviews further reported that C1 had ongoing aggressive behaviors that resulted in altercations with peers, but maintained that staff intervened during these altercations and on some occasions, resulting in law enforcement contacts. The Department received inconsistent information regarding lack of supervision by staff. Based on confidential interviews, the allegation that C1 consumed alcohol and smoked marijuana on the premises, C1 sustained injuries while in care, C1 engaged in physical altercations while in care, and that staff did not intervene while C1 was engaged in physical altercations, may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was emailed to CEO Lawrence Thomas. Copies of the original signatures will be placed with the complaint file.

Investigation Findings:
13On November 2, 2023, at 4: PM, Licensing Program Analyst (LPA), Cynthia Urena met with Pennacle Foundation Short Residential Therapeutic Program (STRTP) Chief Executive Officer (CEO) Lawrence Thomas to deliver the investigative findings for the above stated allegations. This facility was closed effective July of 2023 and this visit took place virtually. On February 1, 2023, at 2: PM, LPA Daniel Mena initiated the investigation at the facility and collected pertinent documents from the STRTP program staff and client files. A health and safety inspection was conducted, and no immediate deficiencies were observed. LPA Mena informed the facility that Special Investigator (SI) Charlotte Jackson would be leading the investigation. Interviews were conducted with a witness, a County Social Worker (CSW), two staff members (S1, S2), and a client (C2). SI Jackson and LPA Urena made multiple attempts to interview Client #1 (C1) however no additional information could be obtained due to C1's unknown whereabouts. Additionally, SI Jackson reviewed a police report, and other pertinent reports involving C1 to assist with the investigation process. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: PENNACLE FOUNDATION INCFACILITY NUMBER: VISIT DATE: 11/02/2023

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

met_with: CEO, Lawrence Thomas


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Specifically, it was reported that S1 did not allow C1 to step outside of the facility to say goodbye to another staff as it was their last day of working at the facility and told C1 that C1 would be reported as leaving the facility without permission if they stepped outside of the facility. C1 walked out the front door and S1 proceeded to lock C1 outside of the facility and did not allow entry from the door. Confidential interviews confirmed that C1 stepped outside of the facility and S1 told C1 that C1 could not come back into the facility unless properly searched and locked the door. Based on confidential interviews, the preponderance of evidence standard has been met and the allegations that S1 did not provide trauma informed interventions and S1 did not allow C1 in care to return to facility are substantiated. The STRTP is being cited for violations of Interim Licensing Standards (ILS), version 5, section 87072(c)(32) for Personal Rights. An exit interview was conducted, appeal rights were explained, and a copy of this report and LIC 811 was provided to Lawrence Thomas, CEO.

Investigation Findings:
13On 05/28/24 at 06: PM, Licensing Program Analyst (LPA) Sarah Lo emailed Lawrence Thomas, CEO, to deliver the findings for the above complaint allegations at Pennacle Foundation, Inc. Short Term Residential Therapeutic Program (STRTP). On 06/21/2023, LPA Erika Lopez and LPA Jason Dalton inspected the facility's physical plant, and no immediate health and safety hazards were observed. The investigation included interviews with one staff (S1), Facility Manager (FM), two Clients (C1, C2) and County Social Worker. On June 20, 2023, Community Care Licensing received allegations stating that staff (S1) did not provide trauma informed interventions and staff (S1) did not allow youth (C1) in care to return to facility. (continued on LIC 9099c) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Sarah Lo LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: PENNACLE FOUNDATION INCFACILITY NUMBER: VISIT DATE: 05/28/2024

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

met_with: Lawrence Thomas, CEO

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
On September 13, 2021 at 11: AM, Licensing Program Analyst (LPA) Carmen Escobar arrived at Pennacle Short-Term Residential Therapeutic Program (STRTP). LPA met with facility manager (FM) Tina Gordon. The purpose of the visit is to conduct an annual inspection of the facility. There was one staff and zero clients present at the time of the inspection. Appropriate staff/client ratios were verified during the inspection, however, the two clients currently placed in the STRTP were at school. LPA conducted the physical inspection 11: AM. FM Tina Gordon led the physical inspection of the facility. The facility consists of three bedrooms and two bathrooms. The facility has a dining area, kitchen area, and living room/common area that also houses the make-shift staff office. The facility also has an attached garage where the washer and dryer are located. The facility does not have a clinician's office for therapeutic services, therefore, counseling and therapy is currently being provided . Staff area is located in the open common area adjacent to the main living room. All bedrooms have two individual twin beds and adequate drawer space for each client. Because there are only two clients placed in the STRTP, they each have their own room. The facility ensures that there is one client per bed with appropriate linens, pillows, comforters, and mattresses in good repair. Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space for the clients. Books, board games, movies, a TV, and video game system, were observed for client's recreation time. Carbon monoxide detector is in appropriate working order, and per staff, all facility smoke detectors are also in working order. The facility maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. The Grievance Procedures were not posted within the facility. The facility is being cited for Interim Licesning Standards section 87072(a)(3): Discipline Policies and Procedures. Other information, such as Personal Rights and Visitation Policy were posted. Medications are locked and centrally stored in a locked file cabinet in the staff area. The hot water in the restroom was deemed to be at a safe temperature. Per facility staff, no firearms or weapons are allowed in the facility. Facility appears to be meeting the terms and conditions of the license. Chemicals and/or poisons are locked in a lower hallway cabinet. Sharp objects are locked and stored in the locked file cabinet in the staff area, as well as the First Aid Kits and First Aid manual. Facility has not yet obtained Mental Health Certification, however, are in process of completing the application. Facility has also not yet obtained national accreditation. There is currently a balance of $681.00 in licensing fees that were due on 08/2021. LPA began reviewing client files for the two clients currently placed in the STRTP, however, was unable to complete the reviews due to time constraints. LPA Escobar will return to complete staff file review and interviews at a later date. An exit interview was conducted and a copy of this report and appeal rights were provided to Facility Manager, Tina Gordon.

report_type: Facility Evaluation

visit_type: Annual

met_with: Tina Gordon-Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On September 15, 2021 at 9: AM, Licensing Program Analyst (LPA) Carmen Escobar arrived at Pennacle Short-Term Residential Therapeutic Program (STRTP). LPA met with facility manager (FM) Watishi Turner. The purpose of the visit is to continue the annual inspection of the facility that was started on September 13, 2021. There was one staff and zero clients present at the time of the inspection continuation. Appropriate staff/client ratios were verified during the inspection, however, the two clients currently placed in the STRTP were at school. LPA Escobar continued to review the client and staff files but was unable to complete the inspection due to time constraints. LPA will return to complete staff file review and client and staff interviews at a later date. An exit interview was conducted and a copy of this report and appeal rights were provided to facility Administrator, Carolyn Ruffin, as facility manager's shift has ended.

visit_type: Case Management

met_with: Facility manager, Watishi Turner & Administrator Carolyn Ruffin


summary: Facility Evaluation

raw_content:
Narrative:
On September 17, 2021, at 1: PM, Licensing Program Analyst (LPA) Carmen Escobar, arrived at Pennacle Short Term Residential Therapeutic Program (STRTP). LPA was greeted and granted access by facility manager, Watishi Turner. The purpose of the visit was to continue the annual inspection that began on Monday, September 13, 2021. There was one staff present at the time of the annual continuation. Appropriate staff/client ratios were verified as the facility has two clients and both were at school during the inspection. Personnel files are kept in a locked file cabinet in the staff area of the living room. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. The facility employs one head social worker, one facility administrator, five facility managers, and one direct care staff. Seven staff files were reviewed at the time of inspection. The Administrator's file was unavailable for review by LPA. Facility is being cited under Interim Licensing Standards (ILS) section 80066: Personnel Records. Four of the five staff files reviewed for facility managers (FM) do not meet the regulation qualifications to be facility managers. There was no documentation of required education and experience in file for the one direct care staff (DC1). There was no documentation of initial new hire staff training for six of eight staff files. Training records for five of seven staff files were incomplete and did not provide accurate records of annual trainings. Facility is being cited under ILS section 87065: Personnel Requirements for all aforementioned staff file deficiencies. Based on LPA's observation, review of LIC500, and confidential interviews, the facility Administrator was not at the facility a minimum of 20 hours as required. The facility is being cited under ILS section 87064: Administrator Qualifications and Duties. A civil penalty was assessed due to citation being a repeat offense. Additionally, board minutes were unavailable for LPA's review. Facility is being cited under ILS section 87063: Accountability. Staff have not been trained or have not maintained their certification to conduct restraints, though the staff state restraints are never used in the facility. Because the facility is an STRTP, it is required that staff maintain their certification for restraints. The facility is being cited under ILS section 87095:Emergency Intervention Staff Training.Lastly, one facility manager (FM5) did not have proof of current CPR/first aid certification in staff file. Facility is being cited under Title 22 section 80075: Health Related Services. Two of two client files were reviewed during time of inspection. Client 1 (C1) did not have a copy of the current JV220 for authorization of C1's psychotropic medications in file. Neither C1 or client 2 (C2) had a visitation list showing who is or is not allowed to visit the client. Additionally, neither needs and service plan for C1 and C2 had all required signatures. The plans also did not have documentation that both client and client's authorized representative were offered the opportunity to participate in the plan development or that authorized representatives approved the needs and service plan for C1 and C2. The facility is being cited under ILS section 87070: Children's Records. C2 did not have proof of medical assessment during the first 30 days in the facility. C1 did not have proof of TB test. The facility is being cited under Title 22 section 80069: Client Medical Assessment. Neither C1 or C2 have received an allowance since arriving at the STRTP. Facility is being cited under ILS section 87072: Personal Rights. There was no record of an initial crisis management assessment in both client's files. Facility is being cited under ILS section 87068.1: Intake Procedures. Based on review of activity calendar, daily schedule, and staff and client interviews, the STRTP is not providing required core services and supports. Facility is being cited under ILS section 87078.1: Core Services and Supports. Technical violations were issued for section 80066: Personnel Records-staff missing proof of educational background in staff files, section 87095.61: Documentation and Reporting Requirements-no restrain log available for review, and section 87068. Needs and Service Plan-no mention of community resources in both client's plans and no mention of how much money clients are permitted to have in their possession. Technical Assistance was issued for section 87065: Personnel Requirements- employee handbook did not include disaster response procedures, and section 87079: Planned activities-no mention of activities from section (a)(1) through (a)(10) on activities calendar. During the three days of annual inspection, LPA interviewed three staff and two clients. Confidential interviews did not reveal health and safety concerns. Both clients indicated that their basic needs are being met at the facility and that they feel safe and secure in the facility. An exit interview was conducted, and a copy of this report and appeal rights were provided to FM, Tina Gordon, as other FM, Watishi Turner, has already concluded her shift.

met_with: Watishi Turner & Tina Gordon-Facility Managers


summary: Facility Evaluation

raw_content:
Narrative:
An informal conference was held with Pennacle Foundation Inc. Short-Term Residential Therapeutic Program (STRTP) to discuss current Community Care Licensing (CCL) concerns. Present at the meeting was LaCresha Cook, Regional Manager, Jennifer Smith, Licensing Program Manager, Carmen Escobar, Licensing Program Analyst, Lawrence Thomas, Chief Executive Officer (CEO), Carolyn Ruffin, Administrator, Dr. Sandra Butler, Board member, Jenell Ross, Riverside Department Public Social Services, Diana Wagner and Stacie Kinney, System of Care Branch, Karen Atkins, Riverside County Placement Liaison, David Gutierrez, Sandi Snelgrove, and Alexandria Andrews, Department of Health Care Services (DHCS), and Nisha Elliott, Riverside Behavioral Health. The following information was discussed: 1. Lack of oversight by management. 2. CCL unable to verify work hours of Administrator and hours present in the facility 3. Lack of trauma informed programming and activities for clients 4. Facility Managers unaware of Facility Manager Training 5. Lack of communication between Facility Management 6. Facility records unorganized and unavailable upon request 7. Clarification of mental health services being provided to clients. 8. Lack of Accreditation, Mental Health Contract, Medi-Cal Approval. 9. Lack of response to Department Health Care Services for denial of Mental Health Application. 10. Staff are not qualified. 11. Staff are not being adequately trained. 12. Plans of correction are incomplete and submitted late. 13. Core services, lack of trauma informed care. who are San Bernardino County placements, are receiving mental health services in Riverside County. This could cause billing issues for the facility. Administrator stated she would obtain clarification on this. 8. CEO and Administrator confirmed the STRTP does not have accreditation, however, are working with CARF representative and have obtained the services of Maria Sarkisian to assist with the application process. CEO confirmed program does not have an approved mental health program as the application was returned by DHCS due to being incomplete. The facility has also not received Medi-Cal approval. 9. The mental health program application (MHPA) submitted by the facility to the Department of Health Care Services (DHCS) was incomplete. DHCS stated the STRTP staff did not respond to the letter that was sent advising that the MHPA was incomplete. CEO stated he was unaware any response to the letter was necessary. DHCS advised the approval process is lengthy and expressed concern that the program may run out of time as the STRTP's second extension expires on 03/18/22. 10. CCL stated STRTP staff need to be re-valuated to confirm facility managers are qualified to be facility managers. LPA mentioned how not having a Facility Manager at the facility has been a reoccurring issue in the past, so somewhere along the line, all direct care workers were converted to Facility Managers, therefore, any staff working would also be the Facility Manager on site. LPA cited that several facility managers, upon file review, do not meet the requirements specified in the ILS either with education or experience. Almost all employees were hired after January 1, 2017, meaning they were not grandfathered into the STRTP program. Administrator states staff qualifications will be re-evaluated, however, feels this concern might only apply to one staff. Administrator stated they have been having issues with Guardian taking several months to clear a staff. Regional Manager Cook advised that if Guardian is taking a excessive amount of time the facility should reach out to LPA Escobar and LPM Smith for assistance. 11. CCL discussed a previous citation due to lack of training for staff. The annual training hours were incomplete, and upon confidential interviews with staff, many could not recall when the last training provided by administration had occurred. Concern was expressed towards facility staff's lack of understanding of trauma informed care. LPA stated upon interviewing facility staff, several employees were unable to define "trauma-informed care". Additionally, during these confidential interviews, it was determined staff are not receiving 14. Lack of trauma informed milieu 15. CEO and Facility Managements Lack of knowledge of STRTP Requirements and Standards of Care 16. TSP Referral Information covered during the informal conference includes: 1. CEO was unaware of most STRTP requirements and has delegated all operational authority to facility Administrator. Board minutes were discussed, including the need for the Board to spend more time addressing the issues of Pennacle Foundation in Lake Elsinore, as many agendas and meeting minutes provided to LPA addressed the Pennacle facility in Fresno. While the facility has many concerning issues occurring at this time, as noted above, they are not a priority per the agendas and minutes provided to LPA. CCL/LPA expressed the need for Board of Directors to be much more involved, provide more oversight to facility, and aware of all issues occurring with the facility. CEO stated he is the direct contact with the Board of Directors, therefore, it was requested for CEO to better communicate facility issues/conditions to the Board. LPA also requested a Board meeting be conducted to address the facility issues addressed during this informal conference. CEO stated he will definitely fill the Board of Directors in on all the concerns expressed by each department in today's meeting CCL and DHCS recommended the CEO become more familiar with the program and provide more oversight and work more closely with the Administrator and Mental Health Head of Service to ensure successful implementation of statutory and regulatory STRTP requirements. 2. STRTP submitted documentation to CCL that did not verify the work hours of Administrator nor the hours present in the facility. The documentation lacked dates, times, and hours. 3. STRTP is not providing a full program to clients, as seen on the activities calendar for clients. Activities scheduled include things such as movies and visits to park or local YMCA. LPA stated during the three consecutive days of STRTP's annual in September, the activities listed on the calendar did not occur. CCL requested for activities provided to clients to be more trauma-informed based on the specific trauma-informed care model being followed by the program. 4. During past confidential interviews with staff, LPA was told by staff that they are unsure if they are considered a Facility Manager. Several staff could not confirm whether or not they had been trained as a Facility Manager. Some facility managers thought they were still "direct care staff" as they were previously. CCL expressed concern with the training being provided to staff, especially since a Facility Manager is required to be on-site when clients are at the facility, per regulations. 5. CCL addressed the lack of communication between management. CEO confirmed that facility's upper management/administration is busy trying to keep up with all the pending requirements that sometimes, they do not fill each other in quickly enough to know what may have recently occurred or developed within the program. Regional Manager Cook stated the Board of Directors, CEO, and Administrator, all need to better communicate to get everyone on same page with facility concerns. CEO agreed. 6. LPA addressed facility's common practice of staff files to be stored "off grounds", sometimes taking hours to be brought to the facility. CCL stated all hard copies of files need to be stored at the facility for reviewing purposes. Though Administrator generally offers to email copies of necessary documents to LPA, it was made clear by CCL all files need to be stored at the facility. LPA confirmed staff files were brought to the Regional Office for review and will be ready for pick up on Monday, December 13, 2021. Documentation of mental health service hours were also discussed. DHCS specifically addressed the need for detailed records including dates, times, and hours, etc. of services provided for each client. The program needs to create a more detailed documentation system. Per DHCS, hours, and additional details, need to be clearly recorded for audit purposes. Same issues exist for documentation of staff training hours. Administrator agreed to get files organized and completed. 7. Administrator states client 1 and client 2 are both being provided mental health services in Riverside County (Lake Elsinore), though they are both San Bernardino County placements. LPA read from facility's program statement stating the clients in the program will receive 1-2 sessions per week of individual therapy and will have group therapy sessions once a week. DHCS pointed out that since the STRTP does not have an approved mental health care program, they cannot be providing these services to clients as of yet. Administrator confirmed clients are receiving off-site mental health care services at this time. Administrator was unsure as to which county provides Medi-Cal to clients. Riverside Behavioral Health expressed there needs to be clarification as to why the clients the required hours of annual training. Training records submitted to LPA previously do not provide the necessary information required per Interim Licensing Standards. LPA advised facility better documentation is needed showing course title and subject matter, learning objectives and activities, number of hours per training session, qualification of trainer, and training evaluation. There should also be a way to confirm staff attendance, either attendance sheet with signature, electronic signature, time stamp records, etc. Supporting documentation of training, if available, should also be provided. Hours completed for each training should be clear for reviewing parties. 12. Plans of corrections (POCs) provided to LPA are generally incomplete and/or untimely. CCL expressed the need for more detailed documentation and records as expressed above. Additionally, CCL confirmed LPA will be following-up with the plans of correction in a timely manner to more quickly bring the facility into compliance. It was also stated that civil penalties are a possible consequence of repeat citations if they are not being properly or sufficiently cleared. LPA expressed a vital component of this occurring is simply the need for more detailed and organized documentation by the facility. Administrator agreed and stated she is always good about submitting everything on time, however, past POCs have been untimely. 13. While trauma informed care is described in the facility's program statement, System of Care Branch and Riverside Regional Office both stated that additional updates are required because the trauma informed sections are not specific and lack detail. 14. System of Care Branch advised a clear trauma informed, evidence-based, model needs to be referred to throughout the entire program statement. This is necessary because depending on the model being used, the trauma-informed practices should be specific to that model; every aspect of trauma informed should be addressed in detail and not described in a general manner. 15. CCL and DHCS recommended the CEO become more familiar with the program and provide more oversight and work more closely with the Administrator and Mental Health Head of Service to ensure successful implementation of statutory and regulatory STRTP requirements. 16. A Technical Support Program (TSP) referral will be made by CCL in order for facility to obtain assistance with the implementation of statutory and regulatory STRTP requirements. Administrator stated that she was planning on requesting help from TSP. The facility has agreed to the following: 1. Staff will submit a Plan of Action to CCL within 30 days, due January 7, 2022. The plan should address updates to the facility's current program statement core services, staff training section including program trainer requirements, trauma informed activities that will be provided to clients and how the activities are developed or selected. 2. Update to program statement should include a clear, evidence-based trauma informed model of care and how this model will be implemented. 3. Program statement should address how trauma informed milieu will be provided to clients. This should include how clinical staff will be working with current staff, including regarding technical interventions. 4. Staff will provide anticipated hire dates for two Mental Health Specialists that are in process of being hired by facility. 5. Administrator hours will be addressed in terms of increased hours at facility, how administrator will provide additional oversight to facility and perspective dates of hire for a permanent administrator and assistant administrator will be provided. 6. Updated LIC500 will be produced reflecting exact Administrator schedule and a detailed sign-in sheet will be created, displaying date, time in, time out, staff signature, etc. CCL has requested finger-print attendance records from August 2021 through the December 9, 2021 for the Administrator. 7. Plan of action will include plan for ensuring Facility Manager is present at all times when clients are at the STRTP. 8. Plan will include how staff qualifications will be re-evaluated (specifically Facility Manager staff). 9. Perspective dates of hire for a Head of Service will be provided. 10. Facility activities schedule from October 2021 through December 9, 2021 will be provided to CCL, along with supporting documentation (such as receipts). Examples of trauma-informed activities to be completed with clients will be provided to CCL. An activity schedule for the next six months will be provided to CCL. 11. Staff training documentation will be reassessed to include all the information required per Interim Licensing Standards (ILS) regulations. Training records will be updated to reflect the ILS requirements. Upon conclusion of the meeting, Pennacle Foundation representatives were advised the goal of the informal conference is to bring the facility into compliance, especially since the STRTP's provisional license expires March 18, 2022. It was also advised that if the Plan of Action is not approved or adhered to, the next step would be conducting a non-compliance conference with the facility, which may result in administrative action. CEO, Lawrence Thomas, was advised the report (LIC809) will be provided via email for signature. Conference was concluded.

met_with: CEO Lawrence Thomas


summary: Facility Evaluation

raw_content:
Narrative:
On July 22, 2022, Licensing Program Analyst (LPA), Carmen Escobar arrived unannounced and met with Facility Manager (FM), William Zachary, in regard to a Confirmation of Removal for individual (A1) identified on the Confidential Names List, LIC 811, dated July 22, 2022. FM states A1's name is unfamiliar to FM and person by A1's name has not worked at facility since FM has been working, which is since November of 2021. FM advised LPA that FM does not know this individual to have been an employee and is definitely not working or currently affiliated with the organization. FM also confirms A1 has no direct contact with any clients at the facility. LPA also confirmed A1 is not listed on the facility's most current LIC500, Personnel Report. Based on evidence obtained during today's visit, the LPA has verified the individual, A1, is not present, employed or residing at the facility. LPA has advised the licensee to disassociate the individual from their roster. LPA Escobar also conducted phsyical inspection of the facility, no health or safety concerns were observed. Exit interview conducted and a copy of the report was left with FM. Verification of removal is complete.

met_with: Facility Manager-Mr. William Zachary


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Latricia Rogers & Licensing Program Analyst Veronica Whitaker conducted a case management inspection November 8, 2022, based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 10 out of Direct Care Staff and 5 out of 5 youth files were reviewed. 3 out of Direct Care Staff and 0 out of 5 youth were interviewed. (See the Confidential Names List, LIC 811, 11/08/22). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the youth file review including the needs and service assessments, youth case plans, and crisis intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Veronica Whitaker observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Carolyn Ruffin, Administrator.

met_with: Carolyn Ruffin- Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On November 18, 2022, at 11: AM, Licensing Program Analyst (LPA) Carmen Escobar conducted an annual inspection at Pennacle Foundation Short Term Residential Therapeutic Program (STRTP). LPA met with Facility Manager (FM) William Zachary and . The purpose of the visit is to conduct an annual inspection of the facility. There were four staff and three clients present during the time of the inspection. Appropriate staff/client ratios were verified during the inspection, through the time of the inspection. LPA conducted the physical inspection about 2: PM. The purpose of the visit is to conduct an annual inspection of the facility. There were four staff and three clients present during the time of the inspection. LPA inspected the facility inside and out with FM. LPA inspected the physical plant and reviewed operational requirements, core therapeutic services, and disaster preparedness. The facility consists of three bedrooms and two bathrooms. The facility has a dining area, kitchen area, and living room/common area that also houses the makeshift staff office. The facility also has an attached garage where the washer and dryer are located. This garage is also used as another staff office area as well as a food storage area. The facility does not have an approved mental health program, therefore, counseling and therapy is currently being provided off site for clients. Another staff office area is also located in the open common area adjacent to the main living room. All bedrooms have two individual twin beds and adequate drawer space for each client; two clients have their own rooms and two clients share one room. The facility ensures that there is one client per bed with appropriate linens, pillows, comforters, and mattresses. Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space for the clients. Books, board games, movies, a TV, and video game system, were observed for client's recreation time, as well as a basketball hoop in backyard. Carbon monoxide detector and smoke detector are in appropriate working order. The facility maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required postings were available at time of inspection, including Personal Rights and Grievance Policy. Facility has fire clearance, however, no copy was available for review at time of inspection. The licensee is being assessed a technical violation under Interim Licensing Standards (ILS) section 80020(a): Fire Clearance. Additionally, the facility does not have provision of emergency power, such as a back up generator. The licensee is being cited under Health and Safety code section 1565: Task Force on Accreditation of Services for Children. Medications are locked and centrally stored in a locked file cabinet in the living room staff area. The hot water in the restroom was deemed to be at a safe temperature. Per facility staff, no firearms or weapons are allowed in the facility. Facility appears to be meeting the terms and conditions of the license. Chemicals and/or poisons are locked in a lower hallway cabinet. Sharp objects are locked and stored in the locked file cabinet in the garage staff area, as well as the complete First Aid Kits and First Aid manual. Client records are stored in a locked file cabinet the makeshift staff area within the common area living room. The staff records are located in a locked cabinet within the office area in the garage. LPAs reviewed the facility personnel report summary and all staff are currently associated to facility. Facility has not yet obtained Mental Health Certification, however, are in process of completing and submitting the application. Facility has obtained national accreditation through CARF, which is valid until March 31, 2025. All facility licensing fees are current. Board minutes were unavailable for review at time of inspection, facility is being assessed a technical advisory under ILS section 87063: Accountability. LPA was unable to complete the client and staff file reviews due to time constraints and technical difficulties. LPA Escobar will return to complete staff and client file reviews and interviews at a later date. An exit interview was conducted and a copy of this report and appeal rights were provided to FM, Mr. William Zachary.

met_with: Facility Manager-William Zachary


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On November 29, 2022, at 10: AM, Licensing Program Analyst (LPA) Carmen Escobar continued the annual inspection at Pennacle Foundation Short Term Residential Therapeutic Program (STRTP) which was started on 11/18/22. LPA met with Facility Manager (FM) Candice Caldwell and Facility Administrator (FA) Carolyn Ruffin. The purpose of the visit is to continue the annual inspection of the facility. There were four staff and three clients present during the time of the inspection. Appropriate staff/client ratios were verified during the inspection, through the time of the inspection. LPA conducted the physical inspection about 10: AM. LPA inspected the facility inside and out and proceeded to review client records. The facility currently has four clients placed, therefore, four of four client files were reviewed during time of annual inspection continuation. It was observed all client's dates of placement were not included on each client's identification (ID) document; it was recommended the date be included on client's ID document on file cover for ease of access. It was observed C1, C2, and C4's placement agreements are not signed by clients. C1 and C4's are not signed by authorized representative. Also, C4's file did not have a Telecommunications Device Notification form (LIC 9158, 5/97) as C4 is deaf. The facility is being cited under Title 22 section 80068, Admission Agreements. It was also observed that files for C1-C4 do not include a record of monthly mental health service appointments being offered by outside providers. All files, C1-C4 did not include a copy of the client risk pre-assessment, however, they were provided by staff upon LPA's request. All files, C1-C4 did not include a copy of the initial needs and service plan completed within 30 days of each client's placement date. C1, C2, and C4 did not have proof of TB test included in files. The facility is being cited under Title 22, section 80069, Client Medical Assessment. Though half of the client's files included receipts of clothing shopping and allowance spending, most files did not have a consecutive history of receipts. Staff advised client use a debit card for all shopping and their weekly allowance as well as clothing allowance are all transferred onto these debit cards. LPA suggested staff print monthly transaction records, and identify each clothing and allowance deposit, for client's (and agencies') easy reference. C4 has not yet been enrolled in school & there is no proof of efforts/communications in C4's file made with authorized representative and/or different school districts regarding enrollment. Facility is being cited under ILS section 87078, Providing Care and Supervision. Clients who share a room, and client's who previously shared a room, do not have a bedroom sharing assessment in their files. Facility is being cited under ILS section 87087, Buildings and Grounds. Permanency and transition services are not mentioned in the needs and service plans for C1-C4. The facility is being cited under ILS Additionally, there is no mention in the needs and service plan of whether client's and client's authorized representative were offered the opportunity to participate in the creation/modification of the needs and service plan. The facility is being cited under Interim Licensing Standards (ILS) section 87068.2, Needs and Service Plan and ILS section 87070, Client Records. When reviewing medication logs, LPA observed that C1 had several dates in September 2022 not initialed for medication dispensement by staff, C1 and C3 had several dates not initialed the month of October 2022, and C4 on 11/05/22. Also, no reason for refusal was provided, as well as no result noted in log from the missed medication. Based on LPA's review of client files, the facility is being cited under Title 22, section 80070, Client Records. Due to no mention of client transitional plans to lower level of care facilities, the facility is being assessed a technical violation under ILS section 87068.3, Modifications to Needs and Services Plan. Also, due to lack of documentation of efforts made in client's files for things like school enrollment, and documentation of receipt of each client's case plan from their authorized representative, the facility is being assessed a technical violation under ILS section 87068.2, Client Records. Facility was reminded to update client files with the initial crisis management assessment from time of client's intake process. C2, C3, C4 do not have specific background information included in their needs and service plans as required per ILS, such as specific reason for placement (neglect, abuse, etc). Needs and service plans for C1-C4 do not include the client's ability to manage finances. Also, C1's needs and service plan does not address personal care/grooming as required. Technical violations are being assessed under ILS section 87068.2, Needs and Service Plan. Lastly, a technical assistance is being assessed due to a lack of documentation of steps taken to facilitate outreach to the family members of the client; per C1's needs and service plan, C1 expressed interest in visits with adult brother (no documentation of efforts made, etc). A review of this annual continuation report was completed with FA, Carolyn Ruffin. A copy of this report was provided to FA via email due to technical difficulties. LPA Escobar will return at a later date to continue and conclude the facility's annual inspection.

Deficiencies:
11462.01: (3) Anticipated duration of treatment and placement, including the transfer plan specified in Section 87068.4(b).

title: of the Welfare and Institutions Code. The needs and services plan shall also include the following information regarding services necessary to meet the child's needs, consistent with the case plan prepared by the placing agency, if provided, and consistent with the Qualified Individual's assessment


summary: Facility Evaluation

raw_content:
Narrative:
On December 20, 2022, Licensing Program Analyst (LPA) Carmen Escobar arrived at the facility to continue the the Annual Inspection which was started on November 18, 2022. LPA Escobar reviewed staff files and interviewed staff and clients. Due to time constraints and technical difficulties, LPA will have to return at a later date to conclude the annual inspection. LPA conducted an exit interview with Administrator and provided them a copy of the signed report.

met_with: Administrator, Carolyn Ruffin


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On December 23, 2022, at 10: AM, Licensing Program Analyst (LPA) Carmen Escobar arrived at Pennacle Foundation Short-Term Residential Therapeutic Program (STRTP). The purpose of the inspection was to complete the annual inspection for STRTP that was initiated on 11/18/22 and continued on 11/29/22 and 12/20/22. LPA Escobar previously began reviewing staff files and completed the staff file review during this inspection. LPA Escobar reviewed six personnel files to ensure they contained all required documentation per Title Regulations and Interim Licensing Standards (ILS). Personnel Files are usually maintained in a locked filed cabinet located within the garage staff office area, which can also be locked. All personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. All staff are associated to the facility as required. Files for staff 1 (S1), staff 2 (S2), staff 4 (S4), staff 5 (S5), and staff 6 (S6) were reviewed. The following observations were made: S6's file is missing a work performance review and S1's work performance review is not signed. The facility is receving an advisory note under section Interim Licensing Standards (ILS) section 87066(b)(6), Personnel Records. S1-S6's hire dates are not specifically noted in each file. The facility is receiving an advisory note under Title 22, section 80066(a)(3), Personnel Records. S6 does not have proof of educational requirements (copy of degrees, transcripts, etc). The facility is receiving an advisory note under Title 22, section 80066(a)(6), Personnel Records. Also, S6 does not have proof of initial new hire training, orientation, shadowing. S3 is a long standing employee, however, the training/orientation/shadowing document in S3's file is blank. Documentation should be provided regarding the original training record. The facility is being cited under ILS, section 87065.1(d), Supervision, Evaluation, and Training Requirements. Lastly, the facility does not have a licensed nurse available to the facility. The facility is being cited under ILS, section 87089.2(a), Nursing Services. Finally, it was observed that while S5 is a facility manager, S5 also holds the title of Case Manager. The position job duties are not included in S5's personnel file. LPA requested it be added to S5's file. Administrator Carolyn Ruffin is present at the facility a minimum of 20 hours a week, as verified by staff schedule and interviews. While the Administrator's STRTP certificate is not current, Administrator provided proof of payment and processing for the Administrator Certificate. Appropriate staff/client ratios were verified during this inspection. Three facility managers/direct care staff were present during annual inspection. Staff were interviewed during the course of the annual multi-day inspection. Staff were able to provide sufficient information in relation to the facility's STRTP program. Based upon the inspection of facility records and interviews with staff and clients, the Licensee appears to be meeting CFT and Core Services/Supports requirements. A copy of this report, the advisory notices, and appeal rights, were provided to Facility Manager, Judith Murphy.

Deficiencies:
87065.1(d): Supervision, Evaluation And Training Requirements

(d) Notwithstanding California Code of Regulations, Title 22, Section 80065(f)(1) through (6), new direct care staff shall complete a minimum of 24 hours of initial training comprised of the 8 and 16 hour training as specified in (1) and (2) below

met_with: Facility Manager-Judith Murphy