summary: Facility Evaluation

raw_content:
Narrative:
On September 25, 2025, at approximately 11: A.M. Licensing Program Analyst (LPA) Sara Luman-Gonzalez arrived at the above Short Term Residential Therapeutic Program (STRTP) for the purpose of conducting a Random Annual Inspection. LPA met with Facility Administrator, Jazmyn Brown who granted LPA entry into the facility. No youths were present at the beginning of the inspection but they arrived later. LPA inspected physical plant of the facility. LPA observed 3 bedrooms and 3 bathrooms and the rear structure. All documentation including Personal Rights, Grievance Policies, and Facility Sketch are posted at the entry area of the house. Carbon Monoxide and Smoke Detectors were tested. Fire Extinguishers were observed fully charged. Water was tested at 108 degrees. First Aid kit was observed to be fully stocked. Cleaning chemicals and Disinfectants were observed to be locked up. There are multiple common rooms available for the youths to occupy. Medications are stored in the staff office behind a locked door and in a locked cabinet. Toilets, wash basin, bath and shower fixtures in good repair/no leaks. Soap and Paper towels were observed in the bathroom area. Laundry Facilities are in the hallway with a schedule of which days which youth and do their laundry. Bedrooms had appropriate furnishings and clean linen. Extra linens were stored in the hall. Facility Motor Vehicle properly maintained with lights, tires, registration/insurance and working seat belts. Facility is free of vermin. Locked Facilities in the rear yard include the counseling office and 2 garden sheds, all met requirements. Complaint Procedures for Youth were reviewed. The previous quarter's of board minutes were also reviewed by LPA. Disaster and mass casualty plan updated and available at the front of the facility. Quarterly Drills conducted and documented in the staff office. Disaster preparedness supplies verified Number of Staff files reviewed 5. Criminal record clearances were verified along with First Aid and CPR. Job Titles and qualifications were verified along with Training Hours. Number of Clients files reviewed 2. Centrally Stored Medication log and Medication Administration log was reviewed and verified. Trauma Informed Practices are implemented as needed and other modes of therapy are used such as Equine Therapy and Healthy Relationships counseling. The following items were reviewed for compliance in the regional office prior to the facility inspection: · Annual fees · Administrator Certificate for: Jazmyn Brown · Emergency Disaster Plan (per H&S Code 1565) · Accreditation Name and Expiration Date: October 2025 · Mental Health Program Certificate Expires: October 2025 · Annual Emergency Intervention Log · Personnel Roster, Facility Sketch, LIC 500, LIC 610C and LIC 308 · Waivers and Exceptions An exit interview was conducted with Jazmyn Brown, Facility Administrator and a copy of this report and appeal rights was left at the facility.

met_with: Jazmyn Brown, Facility Adminsitrator


state: CA

facility_name: KOINONIA HOUSE #2

summary: Facility Evaluation

raw_content:
Narrative:
On July 22, 2025, Licensing Program Analyst (LPA) Sara Luman-Gonzalez arrived at the above facility to conduct a Case Management regarding an incident that was reported to the Department. LPA was greeted by Jazmyn Brown, Facility Administrator and was granted entry into the facility. On July 15, 2025, it was observed by facility staff that there was a medication error with a youth in care, during a routine audit of the chart. The facility observed the youth for any side effects and began a comprehensive re-education and reinforcement initiative with the staff involved in medication disbursement. During today's visit, LPA reviewed the Psychotropic Medication Administration Record (PMAR) & Medication Administration Record (MAR) for 1 youth as well as current medication counts for the month of July 2025. LPA obtained the training that is being provided as a result of the error and logs of who has taken the training as of today's date. During the inspection of the above documentation, LPA observed multiple errors, dated from 7.11-7.19, and regarding the forms and medications. LPA conducted 2 of interviews with Staff. Facility Administrator (FA) took the staff who issued the incorrect medication off of the roster for issuing medications until further monitoring of their progress can be completed along with additional training. Additionally, they contacted the psychiatrist to verify that there were adverse side effects. Based on interviews conducted and records review, it was confirmed that the error reported along with other errors did occur. This is an immediate Health, Safety, and Personal Rights risk to clients in care. A citation is being issued on the attached LIC 809D. An exit interview was conducted and appeal rights were left at the facility.

report_type: Facility Evaluation

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On April 24, 2026, Licensing Program Analyst (LPA) Sara Luman-Gonzalez arrived at 10: A.M., for the purpose of conducting an on site inspection at the above facility. LPA met with William Richardson, Licensee, to conduct a walk through of the facility. The purpose of this inspection was to close the Short Term Residential Therapeutic Program (STRTP) due to the Administrator rescinding the license. Currently, there are still employee's associated but they no longer work there. Licensee (L) William 'Bill' Richardson informed LPA that they are in the process of disassociating everyone with Guardian and that by Thursday April 30, 2026, all employees shall be disassociated. LPA was formally notified of this closure via email April 1, 2026. The reason for the closure is due to Koinonia is closing this STRTP and moving a Group Home (GH) to this location. They have not been providing STRTP services since February 2026 at this location.LPA Luman-Gonzalez was given a tour of the interior and exterior of the facility. The posted license was surrendered. The facility should be closed effective Aril 30, 2026. No citations were issued as a result of this inspection. Exit interview conducted; a copy of this report was provided to the Administrator.

met_with: William Richardson, Licensee


facility_name: KOINONIA HOUSE #3

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Although a new appliance was replaced on 2/11/22, youth was without laundry service during the week that the washer was broken. Therefore, the preponderance of the evidence standard has been met and the above allegation is determined to be SUBSTANTIATED. The facility is cited on the attached 9099D. An exit interview was conducted with Facility Administrator. A copy of this report and the Appeal Rights will be emailed to the agency. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the above allegations; therefore, the above allegations are unsubstantiated. No deficiencies were cited. An exit interview was conducted with Facility Administrator. A copy of this report and the Appeal Rights will be emailed to the agency.

Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion: UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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: Troy Sheridan, Facility Administrator

complaint_status: unsubstantiated


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted with the Administrator. A copy of this report and appeal rights were left with the facility.

Investigation Findings:
UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

met_with: Canaan Sampson, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts Marla Horne and Mary Shelton conducted an unannounced annual inspection of the facility on 9-30-21 at 9: AM. LPAs met with Bill Ryland, Program Director and Troy Sheridan, Facility Administrator. LPAs inspected the facility inside and outside. The facility has three bedrooms and currently has four residents in placement. LPAs observed the bathrooms to have running water at the required temperature. LPAs observed an adequate supply of perishable and non-perishable food items in the kitchen pantry, refrigerators and freezers. Items were labeled in the kitchen cabinets and in the pantry. Knives were locked in a kitchen drawer and medications were in a lock box in a locked cabinet in the staff area. LPAs observed two fire extinguishers and four operable smoke/carbon monoxide detectors. LPAs observed hand sanitizer, masks and COVID-19 posters at the facility entrance. Cleaning supplies were locked in a front hallway closet. LPA's reviewed staff and client files, all required documents were observed in the files. The facility has a swimming pool with a fence and self latching gate. The facility van seats nine and all seat belts are in working order. A first aid kit is located on the driver side of the van. Staff and clients were interviewed. No citations issued during this inspection. An exit interview was conducted with Troy Sheridan.

visit_type: Annual

met_with: Bill Ryland, Program Director & Troy Sheridan , Facility Admiinistrator


summary: Facility Evaluation

raw_content:
Narrative:
On 2/9/22, Licensing Program Analyst (LPA) Stephanie Lor, LPA Tana Kinder, and Program Manager Rosa Rodriguez met with Director to discuss concerns for Koinonia House #5 and #3. The list of concerns include: -Unreasonable consequences for the youth -Staff used of profanity at the facility -Staff usage of personal phone during supervised visit -Denial of phone call to youth to make confidential phone call to the Foster Care Ombudsman. -Youth not allowed to have private phone call conversations with their Social Workers and other professional staff. -Broken washer appliance. Director reported that the staff have been trained on Foster Youth Rights and explained the phone policy for staff and youth. Director will email LPA Lor a revised program statement of the policy. Director will address the concerns with the facility and will follow up with LPA Lor on 2/11/22.

met_with: Bill Ryland, Director


summary: Facility Evaluation

raw_content:
Narrative:
On 3/30/21 at 10:30am, Licensing Program Analyst (LPA), Stephanie Lor conducted a case management interview over the phone regarding personal rights. LPA conducted an interview with the Facility Administrator Assistant. The list of concerns include: -Youth have no privacy in the bedroom -Youth have no access to personal gifts/snacks Staff explained the protocols for when a youth can have privacy in the bedroom, this include when a youth is changing or asking for personal space. Staff explained that youth are allow to have access to their personal gifts/snacks. However, due to another youth in the home who has severe allergic reaction to certain food, staff manages when to provide personal snacks to youth in the home. This case management investigation is closed and no deficiency was cited. An exit interview was conducted with the Facility Administrator Assistant and a copy of this report will be emailed to the facility.

met_with: Marsh Hesh, Facility Administrator Assistant


summary: Facility Evaluation

raw_content:
Narrative:
On 5/10/22 at 2:35pm, Licensing Program Analyst (LPA) Stephanie Lor made an unannounced visit to conduct a case management regarding incidents that were revealed to LPA during a complaint interview. A staff from House 3 informed LPA that House 3 has moved to House 1. This report is created to document this inspection; further investigation is needed.


facility_name: KOINONIA HOUSE #4

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Marla Horne and Cindy Johnson made an unannounced annual/required inspection of the facility on 10-12-21 at 9: AM. LPA's met with facility administrator Jordan Barbour and conducted an inspection of the inside and outside of the facility. LPA's observed required postings of facility license, foster youth rights,emergency evacuation plan as well as evacuation maps. LPAs observed operable smoke/carbon monoxide detectors and fire extinguishers. LPAs observed the kitchen refrigerator, freezer and pantry to have adequate supply of perishable and non-perishable food items. LPAs observed the bathrooms to have warm running water which is required. Bedrooms were observed to have required bedding and furniture. LPAs observed an adequate supply of bedding and linen. The outdoor area was clear of debris. The facility van was observed to have operable brake lights, headlights, turn signals and working seat belts. LPAs observed medications, sharps and cleaning supplies/chemicals to be in a locked cabinet. LPAs reviewed staff and youth files and all required documents were observed in the files. No citations issued during this inspection. An exit interview was conducted with Jordan Barbour.

met_with: Jordan Barbour, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 12.4.24 at 10:00 am LPA Baca met with Facility Administrator Canaan Sampson, Compliance manager Laura Richardson, Program manager Sara Busse. LPA signed the component 2 form and verified photo Id's of all in attendance. LPA discussed next steps and calendared a time for the revisions to be submitted which is December 6, 2024 via Email. Provider will submit the sections highlighted for quicker review. Provider submitted an exemption for the stream in the back of the property that was dated 2015. the provider has a stream in the back of the property that needs to be accessible to the city when needed. The provider will not have young placement's and already has sensors on all windows and doors. the stream is 7 inches deep. LPA verified Administrators certificate. Provider asked for a time frame. LPA stated that there s a possibility that we can license the facility by the end of December, however that depends on when the revisions are received and when the LPA can schedule for the Pre licensing. Fire clearance-Completed Component 2 signed off Completed Component 2 face to face meeting Completed Verification of ID's Completed Credit check - Completed AARS- Completed First review-Completed Tech call with provider and SOC- Completed Fingerprints-Completed

met_with: Canaan Sampson, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Maie Soliman Licensing Program Manager (LPM) Dara Campos conducted an announced Pre-licensing inspection on 4/23/2025 at 10: AM at the above location, as required for the SHORT TERM RESIDENTIAL THERAPEUTIC PROGRAM (STRTP) license. LPA and LPM met with Canaan Sampson, Facility Administrator Supervisor, Sara Busse, Program Director, Alyssa Miller, Office Manager, Aimee MarieL. Zapata, Clinical Facility Administrator. During the pre-licensing visit, LPA and LPM conducted a Health and Safety inspection using the CARE tool. LPA observed the facility was clean inside and safe. The outside of the facility has a canal that runs through the front and back yard. LPA Soliman observed the facility is a one story house. LPA observed three bedrooms and one staff office equipped with appropriate furniture, bedding, and supplies for clients. Sufficient storage space for client's personal belongings was observed in each room. The facility is requesting to be licensed for six youths ranging in age from 13 to 20 years old. LPA Soliman observed a medication Lock box in the staff office, which was empty, but locked, and accessible only to designated staff. The kitchen area was equipped with an adequate amount of utensils, dining supplies, and cups for clients. No food was observed as there are no clients, and no pending placement at this time. Facility will verify required food on hand at time of client placement. LPA observed a staff office space that is locked and inaccessible to clients, it will be utilized as the staff office for storing inaccessible medications and chemicals, in addition to any other item required to be inaccessible to clients. The staff office has a small fridge that will be dedicated to medications if needed. The facility has an attached garage space which houses a fridge and cabinets for extra food storage which is inaccessible to the clients at all times. LPAs observed a wood burner fireplace in the living room with a metal barrier. continued on 809_C page The smoke detectors and carbon monoxide detectors were tested. LPA obtained a copy of the fire clearance dated on 9/23/2024. A fully equipped first aid kit was reviewed and is placed in the staff office. The Foster Youth Bill of Rights was posted in a conspicuous location. There are 2 bathrooms in the facility that are accessible to clients use. The water temperature was tested and found to be not exceeding 120 degrees F. The facility is ready for license as SHORT TERM RESIDENTIAL THERAPEUTIC PROGRAM (STRTP) effective today 4/23/2025. An exit interview waw conducted and a copy of this report was left with Canaan Sampson, Facility Administrator Supervisor.

visit_type: Prelicensing


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Maie Soliman made an unannounced annual inspection on 3/6/2026 at 10:30 am. During the inspection LPA met with Stephanie Luke, Utilization Manager and Daryl Morales, Training Coordinator who assisted with the inspection. LPA Soliman conducted a walk-through of the facility, both inside and outside. There is a canal located in the backyard, for which the facility has an approved waiver. The facility has not had any placement since it was licensed. Number of staff interviewed __one___. LPA observed _three__bedrooms, __three_bathrooms, __one office__ LPA Soliman inspected and/or reviewed the following: I.Physical Plant Posting of license_X__ Personal Rights___X__ Disinfectants/Cleaning solutions inaccessible__X___ Refrigerator Temperature at or below 45 degrees F __X___ Freezer Temperature at or below 0 degrees___X__ Nonperishable Foods one week and fresh perishable foods two days minimum_N/A____ Menu present and posted__N/A____ Working telephone ___X____Carbon monoxide detectors _____X_____Smoke Detector __X___ First Aid Kit fully stocked__X__ Common Room available__X___ Dining area (enough seating, furniture good condition, not broke or damaged) ___X___ Medication centrally stored, locked/inaccessible __N/A___ Office (locked and privacy) ___X____ Hot Water between 105-120-degree F (Properly labeled if over 125 degree F__X____ Fire Extinguisher (note inspection date) __August 2025______Toilets wash basin, bath and shower fixtures in good repair/no leaks/hot water temperature ___X____ Soap and Paper towels ___X___ Laundry Facilities(available) ___X__ Bedrooms-required linen and furnishings __X____ Motor Vehicle properly maintained , lights, tires, registration/insurance and working seat belts___N/A__ Facility free of vermin __X___ Locked Facilities (open locked storage area/building/sheds) ___X___Bedroom (required bedding/furniture, furniture in good repair) __X__ II. Operations Complaint Procedures For Youth Reviewed __X____ Board Minutes Reviewed___X__ III. Disaster Preparedness Disaster and mass casualty plan updated and available___X_____ Quarterly Drills conducted and documented___N/A____ Disaster preparedness supplies verified ___N/A_____ LPA Soliman has not reviewed any client or staff files since the facility has not had any placement since it was lincensed. An exit in terview was conducted with Daryl Morales, Training Coordinator and a copy of this report was left with him.

met_with: Daryl Morales, Training Coordinator


facility_name: LA CHEIM STRTP

raw_content:
Narrative:
Appeal Rights were provided and discussed with the facility, and deficiencies were cited. Exit interview conducted and a copy of the report was left

Investigation Findings:
13Licensing Program Analyst (LPA) Isabel Mendoza conducted a follow-up complaint inspection to the facility and met with Adminstrator, Sonam Prasad. The purpose of the inspection was to deliver the findings for the above complaint allegation. Based on an incident report from January 16, 2020, and interviews, Child #1 (C1) and Child # 2 (C2) (see Confidential Names form (LIC 811) dated {June 16, 2021}) got in a physical altercation, which resulted in (C1's) nose and head bleeding and client falling down the stairs and hitting his head on the wall.. Also, staff would watch clients fight for a short time before intervening. Based on documentation, police reports, and interviews, facility staff did not prevent youths from engaging in physical altercations. Based on the information obtained, there is a preponderance of the evidence. Therefore, the above allegation is substantiated. [Please cont. to LIC 9099.] SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: Isabel Mendoza 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 14-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, TRAEGER AVE., SUITE FACILITY NAME: LA CHEIM STRTPFACILITY NUMBER: VISIT DATE: 06/16/2021

met_with: Administrator, Sonam Prasad.


raw_content:
Investigation Findings:
UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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

met_with: Administrator Sonam Prasad


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
The hired Head of Service does not have a master's degree nor any of the listed licenses. Further, the hired Head of Service has identified themself by multiple titles, including "Residential Director" in their email signature, which is not a listed job title in the approved POO. The preponderance of evidence standard has been met, and therefore the allegation "Head of Service not qualified" is found to be substantiated. Lastly, per applicable licensing requirements and the POO, the facility manager shall have either a bachelor's degree or two years of experience working with the population to be served or equivalent. When hired in October 2022, the facility manager had five months of experience as a direct care staff at the facility. The facility manager had multiple years of experience working with populations outside of the age range and care needs / behavioral backgrounds of the facility population. The preponderance of evidence standard has been met, and therefore the allegation "Facility Manager not qualified" is found to be substantiated. LPA is issuing one citation of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section Personal Rights, one citation of STRTP ILS Section Personnel Requirements, and one citation of STRTP ILS Section Plan of Operation. See attached deficiency pages. An exit interview was conducted, appeal rights were discussed and provided, and a copy of this report was provided to Administrator Sonam Prasad, whose signature on this form confirms receipt.

Investigation Findings:
13On 2/17/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a complaint investigation visit to deliver findings. LPA met with Administrator Sonam Prasad and informed of the purpose of the visit. The investigation consisted of confidential interviews with staff, residents, and witnesses and review of relevant facility records. Based on LPA's investigation, there have been multiple observations among staff and residents of inappropriateness from staff member(s), including wearing inappropriate clothing, inappropriate interactions with clients, and bias/favoritism. The preponderance of evidence standard has been met, and therefore the allegation "Staff being inappropriate with clients" is found to be substantiated. Additionally, based on LPA's investigation, both the Head of Service and Facility Manager are not qualified. The Head of Service may be filling the role as listed in the facility plan of operation (POO), based on review of applicable requirements and the POO, of the Social Worker/Clinical Coordinator or the Program Director. The former requires a master's degree and the latter a LSCW, MFT, or LPCC license. [] SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Mariah Hawkins 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 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CENTRAL COAST SC/RES, TRAEGER AVE., SUITE FACILITY NAME: LA CHEIM STRTPFACILITY NUMBER: VISIT DATE: 02/17/2023

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Based on confidential interviews, the food supply was less than the required amount to meet the needs of the residents in care, including an empty refrigerator in the kitchen. Additionally, at least one resident has purchased their own food and keeps their own food supply in their room and has done so after requesting staff purchase preferred foods and those foods not being obtained and/or prepared. LPA observed the facility to require cleaning and multiple repairs. Outside, LPA observed trash and contraband in the side yard, including an empty water jug, two empty cigarette packs, and one lighter with lighter fluid. LPA removed the cigarette packs and lighter and handed to Administrator for disposal. LPA observed a broken support beam under the back deck that had swung to the ground. Downstairs, LPA observed the bathroom toilet roll holder to be missing with a large screw exposed. The bathroom light switch cover was loose with a loose nail. The dressers in both downstairs bedrooms had missing drawer knobs and sharp screws exposed where the knobs would screw on. In one of the downstairs bedrooms, there is a heavily stained mattress with a hole in it, which Administrator stated would be replaced. The window screens were torn, and the curtain rod was pulled from the wall fixture. Upstairs, LPA observed a dresser with no drawer knobs, resulting in difficulty opening the drawers. There were two large holes in the wall of one of the bedrooms, graffiti on a ceiling beam, on the window, on the dresser, and on the front and back of the door. The graffiti on the door included gang-related symbols/lettering and profanity that speaks negatively of the facility and specific staff members. The door frame is also broken. There is currently a resident in this room, and Administrator stated the graffiti and holes were caused by a former resident and that the current resident moved into the room with this damage present. Administrator stated that the resident cannot be moved to one of the vacant bedrooms downstairs due to a runaway risk. When LPA arrived, there were two residents and one staff, Administrator. One of the residents is a known runaway risk. Staffing should be increased to provide extra supervision and meet this resident's needs. Administrator provided evidence of their correspondence with licensee on getting these issues addressed. The preponderance of evidence standard has been met, and therefore the above allegations are found to be substantiated. LPA is issuing citations of California Code of Regulations, Title 22, sections 80087 and 80088 and Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards sections 87076 and 87065.5. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Sonam Prasad, whose signature on this form confirms receipt.

Investigation Findings:
13On 4/7/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted an initial complaint inspection. LPA met with Administrator Sonam Prasad and informed of the purpose of the visit. CEO Carizma Chapman entered the facility at around 1:45PM. During the visit, LPA conducted a tour of the facility and grounds with Administrator and obtained photos. LPA observed the kitchen trash can to be placed on top of the lid, meaning it was being used without a lid. LPA observed expired food in the upstairs cabinets and refrigerator and in the downstairs emergency food supply, including rotten bell pepper, expired cans of soup and sausages, and old cereal in open bags with no boxes. The emergency food supply log was last updated on 2/19/21 and includes more food than was available in the cabinets, and much of the food was expired. Administrator confirmed more food would be purchased but also confirmed that there was a lot less food last week. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Mariah Hawkins 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 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CENTRAL COAST SC/RES, TRAEGER AVE., SUITE FACILITY NAME: LA CHEIM STRTPFACILITY NUMBER: VISIT DATE: 04/07/2023

met_with: Administrator Sonam Prasad; CEO Carizma Chapman


summary: Complaint Investigation - Unsubstantiated - 1 deficiency

raw_content:
Narrative:
Additionally, facility records reveal that a 14-day notice was issued for a resident with a stipulation that the resident would not be authorized to return to the facility following another psychiatric hold or law enforcement contact. After an incident in September 2022, the resident was released from a hold, and the facility did not pick up the youth. The facility did not follow proper procedures in developing a transition plan for the resident and ensuring trauma-informed care of the resident. The preponderance of evidence standard has been met, and therefore the above allegations are found to be substantiated. LPA is issuing citations of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87061 and Section 87068.4. See attached LIC 9099-D. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Facility Manager Tatiana Good, whose signature on this form confirms receipt.

Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion: UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

Deficiencies:
87061: (C) Description of what manual restraints were used, and how long the child was restrained.

met_with: Facility Manager Tatiana Good

title:
Reporting Requirements
(i)(6) Incident Reports documenting the use of manual restraints must include the following


met_with: Sonam Prasad

investigation_findings: UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

allegations: UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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


summary: Facility Evaluation

raw_content:
Narrative:
SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Oquendo 10/13/21 at 10:00AM. LPA spoke with Administrator - Sonam Prasad, who provided files and documents for review. This inspection was conducted at this facility. LPA reviewed client files and viewed the medications in the office, which were locked in a cabinet, located inside the locked staff office. Facility has a capacity of six, with three children in placement. All three of the children placed at this facility are prescribed psychotropic medications One child was present at the facility during this inspection. The other children were at school. This facility previously received an SB 484 inspection on 11/12/20. LPA conducted exit interview with administrator and left a copy of this report.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Cheyenne McCambridge made an unannounced annual inspection to facility. LPA met with Administrator, Sonam Prasad. The facility currently has three clients in care. No clients were present during inspection. LPA McCambridge toured the facility inside and out. The facility is a two level house. The facility consists of 5 rooms upstairs ( Bedrooms, 1 bathroom, kitchen, living room and dining room). There are 6 rooms downstairs (2 bedrooms, 1 1/2 bathroom (1 for client and 1/2 bath for staff), 1 administrative office, laundry room and storage room. The home is clean, safe, and sanitary. The water measured 117 degrees which is currently between 105 - 120 degrees. The facility has plenty of nonperishable and perishable food supply. Medication, cleaning supplies and knives are locked away. All passageways are unobstructed. All smoke detectors are update and working. There are no firearms on the property. The fire extinguisher has been checked and is up to date. There are no bodies of water on the property. The home is maintained at a comfortable temperature. Required documentation is posted throughout the facility. LPA was unable to review medication binder due to binder being on campus. LPA reminded the facility that medication binder should be on site at all times. LPA McCambridge reviewed staff and client files. All files were observed to be complete and current with required documentation. LPA McCambridge also observed the medication logs to be updated and current. There were no deficiencies cited at today's inspection. Exit interview was conducted and a copy of the report was emailed to Administrator Sonam Prasad.


summary: Facility Evaluation

raw_content:
Narrative:
On 5/24/23, Licensing Program Analyst (LPA) Mariah Hawkins made a case management visit to request documents. LPA met with Facility Manager Tatiana Good and informed of the purpose of the visit. During a visit to the facility, LPA requested the below documentation for review, but these were not provided during the visit. LPA advised that these should be readily available at the facility site for review by the licensing agency. LPA requested that the below items be sent to LPA by Monday 5/29/23 5PM: 1) Pro-Act Certificates valid during the month of September 2022 for all staff working in August-September 2022. 2) Consequences Logs for 2022 to current. 3) Manual Restraint Logs for 2022 to current 4) Needs and Services Plans for current residents for January 2023 through May 2023. An exit interview was conducted, and a copy of this report was left with Facility Manager Tatiana Good, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts Michelle P. Kyane conducted a case management inspection on 7/27/2023 at 11: AM based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 5 out of Direct Care Staff and 2 out of 2 youth files were reviewed. 2 out of Direct Care Staff and 1 out of 2 youth were interviewed. (See the Confidential Names List, LIC 811, 7/27/2023). The Plan of Operation including policies and procedures were reviewed. The minutes of meetings of the board of directors related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth's safety plans, 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 youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Kyane 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 Sonam Prasad , Facility Administrator.


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
On 8/3/23, Licensing Program Analyst (LPA) Mariah Hawkins met with Administrator Sonam Prasad and Facility Manager Lenora Bass. LPA informed Administrator over the phone of the purpose of the visit. Administrator is out on leave and confirmed that S1, who granted LPA entry to the facility and was the only staff on site with one resident present, is not a facility manager. S1 called the Head of Services, who informed that a facility manager was being called in. Facility Manager Lenora Bass arrived at 1:10PM. LPA used the CARE inspection tool to complete this inspection. LPA conducted a tour, file review, and interviews with two staff and one resident. One resident was not present and not available for interview. LPA observed the facility to be clean and organized, kitchen and bathrooms were in sanitary condition, food supply was in quantity and quality to meet residents' needs. The outside space is maintained in safe condition. Personal rights, house rules, grievance procedures, license, and facility sketch are posted where visible to residents and visitors. LPA observed that two employees listed on the LIC 500 and who are required to have a background clearance associated to the facility are not listed as eligible on the clearance roster printed today. See LIC Confidential Names. These staff cannot work on site until a clearance is obtained. LPA observed that personnel files were not available at the facility for review. A continuation visit is required to complete the review of personnel files, including emergency intervention training, first aid/CPR training, and all training certificates. LPA observed, as stated above, that upon entry, there was one staff, who is not a facility manager, and one resident present. There were no other staff present, and LPA requested a facility manager be called. LPA is issuing citations of California Code of Regulations, Title 22, Section Criminal Record Clearance, Section Personnel Records, and Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section Personnel Requirements. See LIC 809-D pages. An exit interview was conducted, appeal rights provided, and a copy of this report was provided to the facility.

Deficiencies:
80019(e): Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility
87065(f): Personnel Requirements

(f) The licensee shall designate at least one facility manager to be present at the facility at all times when one or more children are present

met_with: Facility Manager Lenora Bass


summary: Facility Evaluation

raw_content:
Narrative:
On 08/06/25, Licensing Program Analyst (LPA) Celeste Aparicio made an announced collateral visit to the facility to conduct a confidential interview. LPA met with Sonam Prasad, Administrator and informed the Administrator on the purpose of the visit. During the inspection, LPA attempted one client confidential interview related to an outside investigation. The facility Administrator informed LPA that the client is not at the facility due to being on a runaway. LPA was unable to speak with the client. An exit interview was conducted, and a copy of this report was left with the facility.

met_with: Sonam Prasad, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 01/07/2026,10: AM Licensing Program Analyst (LPA) Cole Oliver conducted an unannounced case management visit to the facility. The purpose of this inspection is to conduct a case management regarding emails from the administrator received by LPA Oliver. LPA met with Administrator, Sonam Prasad and explained the purpose of the visit. The LPA conducted a physical plant at the facility. During the visit, there was three (3) staff members and four (4) clients present at the facility. The facility had informed LPA Oliver two (2) interior safety gate doors had been installed, and cameras had been reinstalled via email. During the visit LPA Oliver observed the safety gates and cameras in the facility, LPA requested copies of the facility sketch and fire clearance certificate. LPA issued one Type A deficiency under California Code of Regulations (CCR) 80086(a) Alterations to Existing Building or New Facilities and one Type B deficiency under CCR 80022(k) Plan of Operation. (Refer to LIC809-D) Addition details (Refer to LIC812) LPA conducted an exit interview; LPAs provided a copy of this report to Administrator, Sonam Prasad whose signature confirms receipt.

met_with: Administrator, Sonam Prasad


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Isabel Mendoza made an unannounced annual inspection to facility. LPA met with Administrator, Sonam Prasad and House Manager, Mentu Omolawa. The facility currently has three clients in care. All clients were at school during inspection. At 11: AM LPA toured the facility inside and out. The facility is a two level house. The facility consists of 5 rooms upstairs ( Bedrooms, 1 bathroom, kitchen, living room and dining room). There are 6 rooms downstairs (2 bedrooms, 1 1/2 bathroom (1 for client and 1/2 bath for staff), 1 administrative office, laundry room and storage room. The home is clean, safe, and sanitary.The water measured 117 degrees F which is currently between 105 - 120 degrees. The facility has plenty of nonperishable and perishable food supply. Medication, cleaning supplies and knives are locked away. All passageways are unobstructed. All smoke detectors are update and working.There are no firearms on the property. The fire extinguisher has been checked and is up to date. There are no bodies of water on the property. The home is maintained at a comfortable temperature. Personal rights, floor plan, food menu and Emergency disaster forms were posted and in clear view. LPA was unable to review medication binder due to binder being on campus. LPA reminded the facility that medication binder should be on site at all times. At 12:30 pm, LPA Mendoza reviewed a total of 5 personnel files. The facility did not have initial training on file for (S2) and (S5) Administrator (please refer to LIC 811, dated 6/16/21 for confidential names). Administrator informed LPA Mendoza that she was trained by two former staff members who no longer work at the agency. Documentation cannot be found at this time. Also, (S2) has resigned and her last day will be tomorrow, 6/17/21. All staff have fingerprint clearances and associated to the facility. All client files were reviewed. The documentation in the clients file were all complete. [Please refer to LIC 809-C for continuation] During inspection, LPA obtained a copy of current LIC 610, LIC 500, fire safety report, and facility sketch. Based on personnel file review the facility will be cited under Title Regulations, Interim Licensing Standards (ILS) Section 87065.1(C) Training Requirements. An exit interview conducted and a report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 10/20/22, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility for a case management inspection. LPA met with Administrator Sonam Prasad and informed of the purpose of the visit. The Licensing agency was informed that the facility caught a staff member on camera footage smoking marijuana on facility grounds. Based on record review and interview with Administrator, the staff member continued to work their shift after smoking marijuana, there were three residents present at this time, and one staff lead working with the staff. The facility had faced some challenges with the staff prior, provided the staff member additional training, and when other staff reported a concern that the staff member had smelled like marijuana one day when they were on shift, the Administrator spoke to the staff member about this less than a month prior and sent a follow-up email. Once the facility became aware of the incident, by seeing the facility camera footage, the staff member was directed to not come to their shift and instead report to the office. The staff member was to be terminated. However, the staff member resigned before showing to the office. LPA reviewed and obtained copies of staff records, including the follow-up email and staff training documentation. Per Administrator, the smoking policy is to not smoke on the premises, inside or outside, and this covers all substances. Staff are not to be intoxicated in any way on their shifts. Apart from onboarding training that all staff receive, no training or reminder about smoking and intoxication has been provided to the staff yet following this incident, but a staff meeting is planned for today, and Administrator agreed to include this as a topic. LPA is issuing a citation of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section Buildings and Grounds and a citation of California Code of Regulations, Title 22, Section Responsibility for Providing Care and Supervision. See attached LIC 809-D. An exit interview was conducted, appeal rights provided, and a copy of this report was provided to Administrator Sonam Prasad, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPA) Alyssa Ng and Shikya Belfield on 10/28/22 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs Ng and Belfield met with Sonam Prasad, Administrator and inspected the facility inside and out. LPA reviewed 2 of child's records and 3 of staff personnel files on site at the facility. LPA reviewed 2 of child's psychotropic medications and medication records. LPA interviewed 2 of staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 2 of children currently prescribed psychotropic medication. LPA provided a copy of this licensing report to Sonam Prasad, Administrator . During the inspection, LPAs observed 3 deficiencies and one Technical Assistance (see attached 809D), plan of corrections were discussed and appeal rights were provided. LPA provided a copy of this licensing report to Sonam Prasad, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On 2/17/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a facility evaluation visit for a case management regarding observed deficiencies. LPA met with Administrator Sonam Prasad and informed of the purpose of the visit. During an investigation at the facility, LPA conducted confidential interviews with staff, residents, and witnesses and review of facility records. Through this, the following was learned and/or observed. The facility does not have a facility manager designated for each shift. Per the plan of operation (POO), "At least one staff member each shift shall be designated as Facility Manager. When the House Manager is working a shift, he is considered the Facility Manager for that shift." Per applicable licensing requirements, there shall be a facility manager present whenever the administrator is absent and children are present, including the night shift. Currently, the facility has one designated facility manager, who is also not fully qualified, and who does not work the night shift. LPA is issuing a citation of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section Personnel Requirements. The facility admitted a youth without consulting with the full team as indicated in the POO, and only provided 1-2 days of notice of the intake. Per the POO, "When possible, the intake interview will include the La Cheim STRTP psychiatric nurse as well as the La Cheim STRTP Program Administrator... Emergency Placements are discussed with our Program Director who will then consider the case and consult with our Psychiatric Team before giving a decision on intake." A recently admitted youth was admitted without consultation with the CCL approved administrator and without the psychiatric team. LPA is issuing a citation of STRTP ILS Section Plan of Operation. An exit interview was conducted, appeal rights were discussed and provided, and a copy of this report was provided to Administrator Sonam Prasad, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 3/9/23, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility to review and discuss plans of corrections (POCs). LPA met with Head of Services Dae'Jah Foster and Administrator Sonam Prasad and informed of the purpose of the visit. The POCs were developed and agreed upon on 2/17/23 for five citations issued on that day, under an LIC 809 and a LIC 9099, both dated 2/17/23. The due date for all POCs was 3/3/23. Submissions were received for 3, and 2 were missing. After the due date, licensee made a request for an extension but did not specify for what or until when. On 3/8/23, a complete request was received. Due to being past the initial due date, the extension is not being granted. At visit, LPA confirmed that the 2 missing POCs were incomplete. These were Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87022(f), due to not following intake procedures outlined in the plan of operation, and Section 87065(f) due to not having facility manager coverage during administrator absence. LPA is assessing two civil penalties for failure to correct, each of $100 per day beginning 3/4/23 and continuing until complete, for a total of $600 each as of today. LPA emphasizes that POCs should be submitted by tomorrow to avoid continuing fees. Additionally, during review of the LIC POC requiring training on consequences, LPA observed that the submitted training slides included discussion of a 10-day consequence for returning after curfew where home visits would be prohibited for 6-9 days. LPA confirmed this has been implemented as a consequence, although it has only recently been implemented for curfew violations. However, the plan of operation (Section 17 of the program statement) states that "discipline will not be used to deny home visits." LPA is issuing a citation of STRTP ILS Section Plan of Operation as well as assessing a civil penalty for repeat violation of $250, as this section was previously cited on 2/17/23. LPA also advises that per STRTP ILS Section 87072, denying home visits without a court order is personal rights violation, so this policy would not be approved. An exit interview was conducted, appeal rights provided, and a copy of this report left with Head of Services.

met_with: Head of Services Dae'Jah Foster; Administrator Sonam Prasad


summary: Facility Evaluation

raw_content:
Narrative:
On 4/7/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit regarding an incident report. LPA met with Administrator Sonam Prasad and informed of the purpose of the visit. The incident report in question indicated that on 3/10/23 a resident was administered three pills, instead of the prescribed dosage of one pill, of the medication Benztropine. The incident report was sent to the Licensing agency on 3/24/23. The staff were retrained the next day and all staff were retrained on medication administration. The facility submitted evidence of this upon request. The written incident report was submitted past 7 days following the incident, as were other reports submitted on 3/24/23, including reports for incidents that occurred on 3/13/23, 3/14/23, 3/15/23, and 3/16/23. LPA is issuing citations of California Code of Regulations, Title 22, sections Health Related Services and Reporting Requirements. See LIC 809-D. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Sonam Prasad, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 4/7/23, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility and observed deficiencies for which this case management report was generated. LPA met with Administrator Sonam Prasad and informed of the purpose of the visit. During the visit, LPA observed a lighter with lighter fluid in it in the side yard. LPA removed the item and handed to Administrator for disposal. LPA is issuing a citation of California Code of Regulations, Title 22, section Buildings and Grounds. Additionally, LPA measured the hot water at both resident bathrooms and observed the temperature to reach 143. F downstairs and F upstairs. LPA is issuing a citation of Title 22, Section Furniture, Fixtures, Equipment, and Supplies. An exit interview was conducted, appeal rights provided, and a copy of this report left with Administrator, whose signature on this form confirms receipt.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 02/26/25 at 10:20am, Licensing Program Analyst (LPA) Celeste Aparicio and LPA Jasmine Cardeno conducted an unannounced visit to the licensed facility. The purpose of this visit was to conduct the required SB Psychotropic Medications inspection. LPAs met with Facility Managers, Michael Mancio and Andrew Dinh, and inspected the facility inside and out. At the time of the inspection, clients in care were present. The facility had two clients that met the criteria for the SB Psychotropic Medication Inspection. LPAs reviewed 2 of child's records and 6 of staff personnel files on site at the facility. LPAs reviewed 2 of child's psychotropic medications and medication records. LPAs interviewed 2 of staff on site to discuss the facilities policies and procedures of operation. LPAs attempted to interview 2 of the children currently prescribed psychotropic medication. During the inspection, LPAs observed deficiencies in 3 of 6 staff files and 1 of 2 deficiencies in client files (see attached 809D), plan of corrections were discussed and appeal rights were provided. LPAs provided a copy of this licensing report to Andrew Dinh, Facility Manager. At this time, the SB Psychotropic Medications inspection is not complete, LPAs will be attempting interviews with clients and staff. LPAs conducted an exit interview with Andrew Dinh, Facility Manager.

Deficiencies:
87070: (13)A copy of the current court order....  for each psychotropic medication...

title:
Children's Records
(b)The following information regarding the child shall be obtained and maintained in the child's record


raw_content:
Investigation Findings:
13On 01/08/26, at 11: AM, Licensing Program Analysts (LPA) Mona Lam and Amee Li conducted an unannounced inspection at La Cheim STRTP, and met with Sonam Prasad, Administrator, who helped with the inspection. The purpose of the inspection was to deliver the complaint finding. The complaint alleged that staff did not prevent children from engaging in inappropriate interactions while in care. During the investigation, LPAs conducted confidential interviews and conducted file review. Based on record review of supervision logs, there are multiple time frames that were undocumented by staff members in conducting their supervision rounds on clients. However, based on interviews, multiple staff and client interviews indicated not witnessing an engagement of inappropriate interactions while in care. In addition, clients' needs and services plans did not indicate concerns of inappropriate behaviors. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation occurred. Therefore, the allegation is UNSUBSTANTIATED. A copy of this report was given to Sonam Prasad, Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Mona Lam LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
is unsubstantiated, and no Title 22 deficiencies were observed. An exit interview was conducted, appeal rights were discussed, and a copy of this report was printed and left with administrator, Sonam Prasad. Whose signature confirms receipt.

Investigation Findings:
UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion: 0

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0


narrative: is unsubstantiated, and no Title 22 deficiencies were observed. An exit interview was conducted, appeal rights were discussed, and a copy of this report was printed and left with administrator, Sonam Prasad. Whose signature confirms receipt.

investigation_findings: UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion: 0

allegations: Unsubstantiated Estimated Days of Completion: 0


facility_name: LIFT UP YOUR HEAD THERAPEUTIC HOMES, INC.

raw_content:
Narrative:
The allegation that facility staff did not ensure that C1 participates in school is related to C1 not attending schooling since October 2020. While the facility staff interviewed stated that they witnessed C1 logging in virtually and engaging in school, regularly. Staff reported that they witnessed C1 completing school work and engaging with teachers while logged on. Facility staff states that C1 was in attendance almost daily and states that despite being in attendance, the facility would get calls daily about not attending school. Staff states that they even called the school office in hopes to rectify the situation but the daily calls continued to be received. CSW states that C1 missing that many days and not being in school is not true. CSW states that C1's school was in direct contact with CSW and had CSW's email but CSW was not notified of any concerns about this prolonged absence(s) from school. LPA sent emails to C1's school requesting information related to C1's attendance 4/9/21 and 8/24/21 and no information was received. LPA was also informed when attempting to contact the school that LPA is not authorized to receive this information without written consent or court order. The allegation that S1 utilized an improper restraint is a result of C1 reporting that C1 was not allowed to leave the staff office when C1 wanted to and that S1 placed themselves between C1 and the exit door. C1 reported that S1 blocked C1 in the staff office and denied C1 the ability to leave the office when C1 wanted to exit. C1 could not recall when this happened. There are no witnesses found and no incident reported that would indicate when this allegation happened or if it happened. S1 denied that C1 was ever blocked in the staff office and prevented to leave at any time. As a result of the investigation and interviews conducted, LPA Hill finds that the allegations that facility staff did not provide minor adequate supervision, facility staff did not ensure that minor participates in school and facility staff utilized an improper restraint are UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with Ms. Johnson and documents were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced tele inspection on 8/27/21 at 10: AM and met with Yoldanda Johnson, Administrator to discuss findings of the complaint allegations as stated. Ms. Johnson was informed that the investigation included an initial virtual inspection at the facility on 4/9/21, a subsequent in-person inspection conducted on 7/16/21, interviews with C1, C2, C3, C4, C5 and C6 (see LIC811 dated 8/25/21) as well as interviews with four staff, complainant and county social worker (CSW). LPA was also provided with C1's Needs and Services Plan and staff contact information. The allegation that facility staff did not provide adequate supervision is related to C1 leaving on an unauthorized absence and staff not shadowing or looking for C1. Incident report received 4/3/21 indicates that C1 did go on an unauthorized absence 3/27/21. After C1 did not return on their own "after giving C1 time", and C1 could not be located in the area, law enforcement was contacted and a missing persons report was filed. CSW stated that they were aware that the facility would give C1 time to calm down and did sometimes follow but not always due to the availability of staff to do this. CSW stated that C1 would usually return on their own after calming down. CSW stated that there was no formal plan related to this time away in the Needs and Services Plan. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., Ste Sacramento, CA Facility Name: Lift Up Your Head Therapeutic Homes, INC.FACILITY NUMBER: VISIT DATE: 08/27/2021

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

met_with: Yoldanda Johnson, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst, (LPA) Tana Kinder conducted an unannounced inspection with Yolanda Johnson at Lift Up Your Head on 8/26/2021 at 1030am to confirm the orders of an Administrative Action. LPA inspected the facility inside and out. No Citations were issued. An exit interview was conducted and a copy of this report was emailed to liftupyourhead@aol.com.

met_with: Yolanda Johnson


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Ignacia Villapudua-Soto, and LPA Jean Stidman arrived at the facility for the purpose of conducting unannounced ANNUAL/RANDOM inspection. LPAs met with Administrator, Rev Randolph Johnson and Administrator Yolanda Johnson on 12/21/21 at 10: AM. LPA Villapudua-Soto conducted a "pre screening" questions prior to a facility inspection due to the Covid-19 pandemic. The home is a three (3) bedrooms, two staff office with three (3) bathrooms, one of the bathrooms is used by staff. LPAs toured the facility inside and outside. LPA inspected the entire facility. All bedrooms are equipped with drawers and closet space and smoke detectors. At today's inspection four clients and three staff were present during the inspection. LPAs reviewed five client files. The following conditions were observed: The home is clean, safe and sanitary throughout. The kitchen has adequate food, fruit, snacks and supplies. The backyard is clean and has adequate space for clients to play and take space. Cleaning supplies and hazardous materials are locked in the laundry room and inaccessible to clients. The extinguishers (2) and first aid kits. The Facility Van was inspected and is in good repair. All bedrooms of the home are equipped with adequate linens, drawers for each client. All required Licensing forms are posted and were observed during inspection. LPA observed a sufficient amount of perishable and non-perishable foods in the kitchen. The food menu is posted on the refrigerator along with personal rights. The home has games, and movies for the clients. LPA's were not able to complete the inspection due to technical issues and will return at another date to complete the inspection. LPA's discussed deficiency concerns with the licensee.

met_with: Reverend Johnson Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst, (LPA) Ignacia Villapudua-Soto arrived at the above STRTP to conduct a Case Management inspection on 1/20/22 at 3: PM. LPA Villapudua-Soto met with Janae Moore, Direct Care staff, Administrative Assistant. Community Care Licensing received an incident report dated 1/10/22 pertaining to C1 being picked up at school. C1 entered the van and tried to change the channel on the radio. Staff reminded client that he was listening to his music and changed the radio station. C1 stated that music was a coping skill and needed to listen to his music. C1 attempted to change the music station and staff then placed his hand on C1's hand and asked not to change the radio station. This activity went back and forth 2 or 3 times. The client exited the van upset and returned to the school. The staff left client at the school. LPA interviewed C1; LPA will return to the facility for further interviews. No deficiencies were cited at this time. Further investigation is needed.

met_with: Janae Moore, Direct Care Staff, Administrative Assistant.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
Licensing Program Analysts (LPA) Ignacia Villapudua-Soto arrived at the facility for the purpose of conducting unannounced Continuation ANNUAL/RANDOM inspection on today's date, 01/24/22 at 1: PM. LPA's Ignacia Villapudua-Soto and Jean Stidman met with Administrator, Rev Randolph Johnson and Administrator Yolanda Johnson on 12/21/21 at 10: AM for the ANNUAL/Random, however, LPAs were having computer issues and were not able to complete the Annual/Random at that time. LPA Villapudua-Soto conducted a "pre screening" questions prior to a facility Continuation Annual/Random due to Covid-19 pandemic". LPA Villapudua-Soto conducted interviews with the clients and staff and used the care tools. The facility is cited for violation of California Code of Regulations, Title 22, Division Six, Regulation 80065(g)(1), 87070(c)(1),87070(c)(3), 80069(a), 80019(e), 80069(c)(1),80066(a)(10) and Civil Penalties Refer to 809D for Title 22 deficiencies cited. Exit interview was conducted with agency Social Worker **Confidential names list provided** **Appeal rights given***

Deficiencies:
80019(e): Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility

met_with: Rev Johnson, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 6/16/ Licensing Program Analyst (LPA) Jean Stidman met with Yolanda Johnson Executive Director, Reverend Johnson Administrator & Founder, Carla Boatner Head of Service, for the purpose of an Office Meeting. During the meeting LPA reviewed sample documentation for April 2022. LPA advised the facility on what documentation is missing and the expected documentation in support of the condition of licensure and their plan of correction. These sections were reviewed: Conditions that Apply to Specific Sections of the Plan Of Operation Plan of Operation Section D: Plan For The Supervision, Evaluation, and Training Of Staff Plan of Operation Section F: Admission Determination Procedures Plan of Operation Section H: Transition or Transfer Policies and Procedures Plan of Operation Section K: Community Resources to be Utilized Conditions That Apply to Specific Sections of the Program Statement Program Statement Section 1: Population to be Served Program Statement Section 4: Core Services Program Statement Section 6: Development, Review implementation and Modification of Needs and Services Program Statement Section 11: Complaints and Grievances Program Statement Section 22: Mental Health Program Approval

met_with: Yolanda Johnson Executive Director


summary: Facility Evaluation

raw_content:
Narrative:
On November 28, 2022, at PM an In- Office informal Conference was held with the Lift Up Your Head STRTP (LUYH). The following people were in attendance: Regional Manager Margo Castaneda (RM), Licensing Program Manager Dara Campos (LPM), Licensing Program Analyst Jean Stidman (LPA), Yolanda Johnson Executive Director (ED), Reverend Johson Administrator (AD), Mia Washington facility board member, Marjana Jackson Manager with Systems of Care (SOC), Michael Ford SSM Foster Care Rates SOC branch, Craig Pedrucci Division Chief with San Joaquin County, Kim Pawlowicz Licensing Program Analyst (LPA2) attended in person. Cynthia Poulos, Melissa Guerrero and Donna Bickham with San Joaquin County Behavioral Health Services attended via Microsoft Teams. The following information was discussed: · Failure to meet condition of the facilities Provisional License · Denial Letter for Short Term Residential Therapeutic Program (STRTP) - Closure Plan · Appeal Rights for the denial of the applications LPA Jean Stidman and LPM Dara Campos reviewed and discussed the report with Reverend and Yolanda Johnson. A copy of the report was provided to Reverend and Yolanda Johnson. A copy of the signed report will be placed in the facility file.

met_with: Yolanda Johnson Executive Director, Reverend Johson Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 1/18/2023 at approximately 10: AM, Licensing Program Analyst (LPA) Kim Pawlowicz met with Rev Randolph E. Johnson, facility administrator for the purpose of an unannounced case management inspection to ensure closure of the STRTP license. Current census is 2 with a proposed capacity of 4. Administrator did not have a current roster of clients but provided the names, DOB, name of social worker and date of placement to LPA. Administrator states he is currently in the process of applying for an FFA license with Alternative Family Services, Sacramento. LPA performed a walk through of the facility and observed one bedroom with two beds that are currently occupied by clients and their belongings. Food supply was adequate and chemicals were locked in a closet. LPA requested forfeiture of the license however administrator could not find the hard copy. Last date of client attendance with STRTP license according to Rev Johnson was 12/22/2022. No citations were issued during this inspection. An exit interview was conducted with Rev Randolph E Johnson, Administrator and a copy of this report was emailed to revrjohnson@gmail.com.

met_with: Rev Randolph E Johnson, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced case management inspection was conducted by Licensing Program Analyst (LPA) Ignacia Villapudua-Soto on 01/24/2022 at 2: PM. During the inspection, LPA met with Administrator Yolanda Johnson. An initial inspection was conducted on 1/20/22. LPA discussed an incident report submitted to Community Care Licensing on January 10, 2022, concerning client 1 regarding an incident (Refer to confidential name's list, LIC 811) where C1 was picked up from school upon entering the vehicle, C1 turned off the music that was listening to. S1 reminded client that he was listening to music and turned his music. C1 was angry due to being picked up from school and not participating in school track. C1 changed the radio station to his music and staff placed his hands on C1 hand and squeezed it. C1 became angry and stated that this was his coping therapy to listen to music and asked the staff not to touch him. This activity went back and forth 2 or 3 times. C1 was angry and was yelling at the staff never to touch him again and C1 exited the van and walked back to school LPA interviewed C1, S2 and Administrator regarding this incident. LPA obtained additional information to support the incident that Staff did squeeze C1's hand. The facility will be cited 87072(d)(11)To be free of physical........ emotional, or other abuse, and from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature including, but not limited to, interference with the daily living functions ....withholding of shelter, clothing, or aids to physical functioning. Refer to LIC 809 for Title 22 deficiencies cited. Exit interview was conducted. **Confidential names list provided** **Appeal rights given***

met_with: Yolanda Johnson, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 5/18/ Licensing Program Manager (LPM) Dara Campos and Licensing Program Analyst (LPA) Jean Stidman met with Yolanda Johnson Executive Director, Reverend Johnson Administrator & Founder, Carla Boatner Head of Service, Janae Moore Administrator for the purpose of an Office Meeting. During the meeting LPM and LPA discussed the documentation submitted for conditions of the facility's provisional license from January 2021-March 2022 does not meet the provisional license conditions. Facility is cited under the California Code of Regulations, Interim Licensing Standards sections 87022(f) Plan of Operation and 87022.1(d) Program Statement, Upon review of documentation submitted from January 2021 -March 2022 facility failed to meet nine out of nine of the following areas: Conditions that Apply to Specific Sections of the Plan Of Operation Plan of Operation Section D: Plan For The Supervision, Evaluation, and Training Of Staff Plan of Operation Section F: Admission Determination Procedures Plan of Operation Section H: Transition or Transfer Policies and Procedures Plan of Operation Section K: Community Resources to be Utilized Conditions That Apply to Specific Sections of the Program Statement Program Statement Section 1: Population to be Served Program Statement Section 4: Core Services Program Statement Section 6: Development, Review implementation and Modification of Needs and Services Program Statement Section 11: Complaints and Grievances Program Statement Section 22: Mental Health Program Approval LPM stated the facility will submit provisional license condition documentation for April-June 2022 by 7/15/22, July-September 2022 by October 14,2022 and October-December 2022 by December 31, 2022.

met_with: Yolanda Johnson Executive Director & Reverend Johnson Administrator & Founder


facility_name: LIGHTHOUSE MENTORING CENTER 2

raw_content:
Narrative:
Although the allegation may have happened or is valid, based on LPA's observations and interviews with residents and staff, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. Therefore, the allegation is Unsubstantiated. An exit interview was conducted, and a copy of this report left with Administrator Nina Davis, whose signature on this form confirms receipt.

Investigation Findings:
UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

met_with: Administrator Nina Davis


summary: Complaint Investigation - Substantiated - 1 deficiency

raw_content:
Narrative:
LPA was able to identify the locations of the incidents by touring the facility and comparing against the footage. LPA obtained photos of the locations for verification. Administrator confirmed that the supervision policy is that when two or more residents are upstairs, there should be a staff member with them. Staff supervision, had procedure been followed, could have prevented the incidents from occurring and/or staff could have intervened to prevent R1 from being filmed and assaulted by peers. The preponderance of evidence standard has been met, and therefore the above allegations are found to be Substantiated. There are two citations, per Interim Licensing Standards, Sections 87065. Personnel Duties and Personal Rights. An exit interview was conducted, appeal rights provided, and a copy of this report left with Administrator Erin Rogers, whose signature on this form confirms receipt.

Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

Deficiencies:
87065.21: (1) Supervision, protection, and care of children at all times, individually and in groups.

title:
2
3
4
5
6
787065.2 Personnel Duties
Direct care staff shall perform the following duties


raw_content:
Narrative:
The preponderance of evidence standard has been met, and therefore the above allegation(s) is/are found to be Substantiated. LPA is issuing a citation of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87095.00(c)(2) General Provisions. An exit interview was conducted, appeal rights provided, and a copy of this report left with Administrator Nina Davis, whose signature on this form confirms receipt.

Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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


raw_content:
Narrative:
The preponderance of evidence standard has been met, and therefore the above allegation(s) is/are found to be Substantiated. LPA is issuing a citation of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87072(c)(10) Personal Rights. An exit interview was conducted, appeal rights provided, and a copy of this report left with Administrator Nina Davis, whose signature on this form confirms receipt. It was reported that staff S1 made threatening statements to R1 and threatened to hit R1, but staff denied and no witnesses confirmed statements. Although the allegation may have happened or is valid, based on LPA's observations and interviews with residents, staff, and witness, there is not a preponderance of the evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegation is Unsubstantiated. An exit interview was conducted, appeal rights provided, and a copy of this report left with Administrator Nina Davis, whose signature on this form confirms receipt.

Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion: UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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


raw_content:
Investigation Findings:
13On 12/28/22 at 1: PM, Licensing Program Analyst (LPA) Alyssa Ng conducted a complaint inspection at The Lighthouse Mentoring Center 2 located at Buckeye Way, Antioch, CA 94509 and spoke with Geramani Martin, Facility Manager. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the investigation, LPA Ng reviewed documents and conducted interviews with client and staff. All interviewed parties stated there is sufficient staffing to meet minors needs. In addition to the confidential interviews, LPA also reviewed their staff schedule and found that there is enough staff to ensure proper supervision. Although, the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that there is insufficient staffing to meet minors needs. Therefore, the above allegation are unsubstantiated. Exit interview was conducted and a copy of the report was left with Geramani Martin, Facility Manager. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Alyssa Ng LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

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

met_with: Geramani Martin


raw_content:
Investigation Findings:
13On 6/27/23, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility to open a complaint investigation of the above allegation. LPA met with Administrator Nina Davis and informed of the purpose of the visit. LPA conducted confidential interviews and obtained relevent documentation and contact information. Based on confidential interviews and record review, the preponderance of evidence standard has been met, and therefore the above allegation is found to be substantiated. LPA is issuing a citation of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) section 87065. Personnel Duties. See LIC 9099-D attached. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Nina Davis, whose signature on this form confirms receipt. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Mariah Hawkins 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 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CENTRAL COAST SC/RES, TRAEGER AVE., SUITE FACILITY NAME: LIGHTHOUSE MENTORING CENTER 2FACILITY NUMBER: 075650005

Deficiencies:
87065.2: (2) Supervising...ensuring appropriate care and supervision is provided ... in accordance with applicable law, licensing regulations, and...facility's policies.

title:
Personnel Duties
(a) The facility manager(s) shall... be responsible for


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
LPA is issuing citations of Short-Term Residential Therapuetic Program (STRTP) Interim Licensing Standards (ILS) sections 87065.2 and 87074. See LIC 9099-D attached. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Nina Davis, whose signature on this form confirms receipt.

Investigation Findings:
13On 7/24/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted an initial visit to the facility regarding an investigation into the complaint allegations listed above. LPA met with Administrator Nina Davis and informed of the purpose of the visit. Based on confidential interview, record review, and observation, the preponderance of evidence standard has been met, and therefore the above allegations are found to be substantiated. It was found that a plan was made with a 13-year-old resident's authorized representative to transport the resident to the airport and meet with the authorized representative, who would be accompanying the resident on the flight. Staff provided transportation to the airport but not to the authorized representative as agreed and therefore did not follow the transportation plan. Staff left the resident unattended at the wrong terminal without a phone, ID, or plane ticket and did not meet with the authorized representative nor inform them of arrival to the airport. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Mariah Hawkins 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 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CENTRAL COAST SC/RES, TRAEGER AVE., SUITE FACILITY NAME: LIGHTHOUSE MENTORING CENTER 2FACILITY NUMBER: VISIT DATE: 07/25/2023


raw_content:
Narrative:
After the review of documentation and interviews with relevant parties, it was found that the allegations could not be corroborated due to insufficient evidence. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violations did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted, appeal rights were provided, and a copy of this report was left with Facility Manager.

Investigation Findings:
13On 3/7/25, Licensing Program Analysts (LPAs) Celeste Aparicio and Cole Oliver made an unannounced inspection to the facility for the purpose of delivering findings from a complaint investigation. LPA met with Galone Parker,Facility Manager and informed Facility Manager on the purpose of this visit. LPA reviewed documentation and conducted confidential interviews. Through the investigation it was found that on 12/30/24 a resident in care had been awake in the middle of the night displaying disruptive behaviors. During this incident the youth had been moving from the inside of the facility to the outside front yard. The complaint alleged that as staff attempted to redirect the youth, staff handled youth in a rough manner and staff did not treat youth with dignity. (See LIC9099-C). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Celeste Aparicio 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 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE FACILITY NAME: LIGHTHOUSE MENTORING CENTER 2FACILITY NUMBER: VISIT DATE: 03/07/2025

met_with: Facility Manager, Galone Parker


raw_content:
Investigation Findings:
13On 3/7/25, Licensing Program Analysts (LPAs) Celeste Aparicio and Cole Oliver made an unannounced inspection to the facility for the purpose of delivering findings from a complaint investigation. LPA met with Galone Parker, Facility Manager and informed Facility Manager on the purpose of this visit. LPA reviewed documentation and conducted confidential interviews. After the review of documentation and interviews with relevant parties, it was found that the allegations could not be corroborated due to inconsistent evidence. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violations did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted, appeal rights were provided, and a copy of this report was left with Facility Manager . UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Celeste Aparicio LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2


raw_content:
Narrative:
The preponderance of evidence standard has been met, and therefore the above allegations staff restrained a minor resulting in injuries and staff handled minor in a rough manner are found to be SUBSTANTIATED. LPA is issuing citations of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87022(f) Plan of Operation, and Section 87072(c)(16) Personal Rights. (See attached LIC9099-D). An exit interview was conducted, appeal rights were provided, and a copy of this report was left with the Administrator, whose signature on this form confirms receipt. After the review of documentation and interviews with relevant parties, it was found that the allegation could not be corroborated due to inconsistent statements obtained. Although the allegation may have happened or is valid, based on LPA's observations and interviews, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. Therefore, the allegation staff pulled a minor's clothing off is UNSUBSTANTIATED. An exit interview was conducted, appeal rights provided, and a copy of this report left with the Administrator .

Investigation Findings:
13On 4/16/25, Licensing Program Analyst (LPA) Celeste Aparicio made an unannounced inspection to the facility for the purpose of delivering findings from a complaint investigation. During the inspection, LPA met with Administrator, Victoria Robertson and informed the Administrator on the purpose of this visit. The complaint alleged staff restrained a minor resulting in injuries and staff handled minor in a rough manner. Based on confidential interviews and records review, it was found that on February 3, S1 and C1 (see LIC811 dated 4/16/25) were involved in a physical struggle which led to the client being restraint inappropriately on their bed and staff handling the minor in a rough manner, which resulted in C1 obtaining bruising by their neck. (LIC9099-C dated 4/16/25) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Celeste Aparicio 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 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE FACILITY NAME: LIGHTHOUSE MENTORING CENTER 2FACILITY NUMBER: VISIT DATE: 04/16/2025

met_with: Administrator, Victoria Robertson


summary: Facility Evaluation

raw_content:
Narrative:
On Tuesday 9/21/21 at 9:50AM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility to conduct the required annual inspection. LPA met with Administrator Nina Davis and Facility Manager Ike Davis. LPA made a pre-visit screening call and safety precautions were taken, including hand hygiene and mask-wearing. LPA used the Inspection Tool to conduct the inspection. LPA inspected facility site, conducted interviews with all present staff and residents, and reviewed all current staff and client files, including files for recently discharged resident and staff who recently left facility. At 4:45PM, LPA had completed the inspection. An annual continuation will need to be completed in order to finalize the report and any citations or advisories. An exit interview was conducted, and a copy of this report was provided to Administrator Nina Davis, whose signature on this form confirms receipt.

met_with: Administrator Nina Davis; Facility Manager Ike Davis


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Britanee Windom conducted a case management inspection on 03/15/22 at 9: AM 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 3 out of 3 youth files were reviewed. 4 out of Direct Care Staff and 3 out of 3 youth were interviewed. (See the Confidential Names List, LIC 811, March 15, 2022). 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 confidential interviews and youth file review including the needs and service assessments, quarterly assessments, and crisis intervention plans, the licensee uses trauma informed and evidence based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Windom 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 Administrator Davis.

met_with: Administrator Davis


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Brian Bertoli on the above date. During the inspection, LPA Bertoli met with Administrator Nina Davis and Facility Manager Keylai Boughton and inspected the facility inside and out. LPA reviewed 2 child records on site at the facility starting at 11:30 am. LPA reviewed 5 staff personnel files on site at the facility at 1:30pm. LPA reviewed 2 child psychotropic medications and medication records at 1:15pm. LPA interviewed 2 staff on site starting at 11:00am. LPA interviewed 2 children currently taking psychotropic medication starting at 10:30am. LPA provided the Summary Report to facility upon completion. No deficiencies are being cited at this time. An Advisory note was given on ILS section 87068. Needs and Services Plan. LPA conducted exit interview with Nina Davis and Keylai Boughton at 2:45pm

met_with: Nina Davis and Keylai Boughton


summary: Facility Evaluation

raw_content:
Narrative:
On 10/6/22 at 11:18AM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility for an inspection. LPA met with Administrator Nina Davis and Facility Manager Keylai Boughton and informed of the purpose of the visit. LPA used the CARE Inspection Tool to conduct this inspection. Two staff and four residents were present. No residents were interviewed due to not agreeing to be interviewed. The facility grounds were inspected, and LPA will return to complete the inspection. Medications, chemicals, and sharps are stored where inaccessible to residents. Personal rights, Licensing contact information, and grievance procedures are posted in the facility. License and facility sketch are posted. There are no firearms on the premises, per Administrator, and no dangerous items were observed by LPA. Residents were observed to be clean in well-fitting clothes, engaged in activity together and with staff, and comfortable with staff and other residents. Facility has a large supply of food of good quality and within date, and staff confirmed that food out of date is never served and staff check at least bi-weekly and when preparing meals to ensure food quality. During visit, LPA observed that the facility van, which staff confirmed is in use, has a large crack across the front of the windshield. LPA is issuing a citation of California Code of Regulations, Title Section 80074. See attached LIC 809-D. An exit interview was conducted, appeal rights provided, and a copy of this report sent to Administrator Nina Davis, whose signature on this form confirms receipt.

met_with: Administrator Nina Davis, Facility Manager Keylai Boughton