summary: Facility Evaluation

raw_content:
Narrative:
On 07/26/24 at 09:57AM Licensing Program Analyst (LPA) Jhane Haynes made an unannounced visit to the above facility for the purpose of conducting a pre-licensing inspection. LPA met with Program Manager(PM) Alley Jensen who granted access to the facility. Together LPA and PM toured the home inside and out. This is a six-bedroom, four-bathroom single-story home with barn access in rural area. There are no swimming pools or bodies of water of the premises. LPA observed the following during facility tour: Entry: contains required postings including personal rights, house rules and complaint procedures, rug, and entry to staff office. Staff Office contains desk, chairs, secured cabinets for medications, nails polish, old batteries, sharps, and nail products. There is also a secured cabinet for client files and door leading to the garage. Garage contains computers for school, couch, TV, and door leading to storage space. It contains emergency food supplies, refrigerator, additional storage shelves and door to building exterior. Water heater is located here. Left Hallway contains locked storage closet that holds extra first aid, hygiene and cleaning supplies. Leads to three client bedrooms, linen cabinet, and staff hallway. Bedroom #1 rooms C5 and contains a twin bed, dressers, and adequate closet space. Bathroom#1 contains hampers, functioning toilet, double sinks, and shower with running water. Bedroom #2 rooms C4 and contains a twin bed, dressers, ceiling fan and adequate closet space. Bedroom #3 rooms C3 and contains a twin bed, dressers and adequate closet space. Staff Hallway leads to two office spaces, laundry area and staff bathroom. Therapist Office for individual/family therapy. It is equipped with soundproofing tiles, couch, chairs, desk and door leading to exterior. Med Room/Milieu Office contains cabinets for locked medications, desk and chairs. Laundry Space contains washer and dryer, storage cabinets for laundry supplies. Bathroom #2 contains functioning toilet, sink and shower with running water. (Continued on LIC809-C) Living Room contains adequate seating for clients, TV, Bookcases, rug, fireplace that is inaccessible to clients. Switch is in locked office. Kitchen/Dining contains center island with three chairs, dishwasher, four burner stove and oven in operating condition, refrigerator, and microwave. Adjacent to the refrigerator is a walk-in pantry. Menu is posted on the fridge. There are perishables for up to two day and non-perishables for up to a week. Fridge operates at 37 degrees and the freezer at 0. Grocery shopping is done weekly. There are adequate dinnerware for clients and secured cabinets for daily cleaning supplies. There are sliding glass door that leads to exterior. Right Hallway leads to three client bedrooms, bathroom, and sensory room. Bathroom #3 contains functioning toilet, double sinks and shower with running water. Breakout/Sensory Room contains large bean bags, activities and soundproof tiles. Clients are accompanied by staff in this room. Bedroom #4 rooms C1 and contains a twin bed, dressers, and clothing rack. Bedroom #5 rooms C2 and contains a twin bed, dressers, and clothing rack. Bedroom #6 is vacant and contains a twin bed, dressers and clothing rack. Exterior opens up to large green area, there are tables and chairs, small fountain, and tortoise enclosure. Left side of property houses solar panels and standing wells of the far side of property which ladder are locked and inaccessible to clients. 1/3 of Barn contains office, half bathroom and group therapy space. It contains a TV, couch, table, chairs and secured activity cabinets. There is a door leading to exterior. Fire extinguishers are located throughout the facility. The facility utilizes two vans to transport youth in operating condition with current registration and insurance. Due to time constraints, LPA will return to complete inspection. No deficiencies will be cited at this time. An exit interview was conducted, and a copy of this report was emailed to the Program Manager.


state: CA

facility_name: TMHA-YOUTH TREATMENT PROGRAM

summary: Facility Evaluation

raw_content:
Narrative:
On 07/26/24 at 09:57AM Licensing Program Analyst (LPA) Jhane Haynes made an unannounced visit to the above facility for the purpose of conducting a case management inspection following an incident report received by the department on 07/23/24. Possible inappropriate interaction between staff and client. LPA met with Program Manager(PM) Alley Jensen who granted access to the facility. LPA conducted interviews with C1, S1 and PM. LPA obtained contact information of S2 and supervising social worker of C2. Further investigation is needed to determine whether a violation occurred. No deficiencies will be cited at this time. An exit interview was conducted, and this report was emailed to the Program Manager.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Alley Jensen Program Manager(PM)


summary: Facility Evaluation

raw_content:
Narrative:
On April 8, 2025 at 3: PM Licensing Program Analyst (LPA) Connie Jones-Steward made an announced visit at TMHA Youth Treatment Program to conduct the SB Psychotropic Medication Inspection. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9(a)(2). LPA conducted a Health and safety risk assessment upon arriving at the facility. During the inspection, LPAs Jones-Steward met with the Administrator Allison Jensen and conducted a brief walk through of the physical plant inside and out. LPA observed no physical plant deficiencies LPA was informed that only two clients met the SB484 review criteria. LPA reviewed two (2) client medical binders and Needs and Services Plans. LPA Jones-Steward interviewed 1 client as the other was not available . LPA reviewed the LIC-500 to confirm that all staff have criminal background clearances. LPA also conducted a physical count of the existing medication with the aid of the administrator. LPA Jones-Steward will conduct staff file reviews and interviews on April 9th, 2025. No deficiencies were found on this date.

met_with: Allison Jenson, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward met with Administrator Allison Jensen on 04/09/2025 to complete the SB 484 inspection. LPA reviewed three staff files and conducted two staff interviews. LPA Jones-Steward issued no deficiencies regarding staff training or knowledge in the area of psychotropic medication handling. However one technical advisory was issued, This concludes the SB Inspection for 2025. Exit interview was conducted and the administrator was given a coy of this report.

met_with: Allison Jensen, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On May 14,2025, at 11:55 am, Licensing Program Analyst (LPA) Nestor Gomez arrived at the above facility, for the purpose of conducting an Annual Required Inspection on the TMHA - Youth Treatment Program (STRTP) facility. LPA Gomez met with Facility Manager (FM), Laila Ness who granted access to the facility. The annual fees are current. Together LPA and Facility Administrator (FA), Allison Jensen toured the home inside and out. The facility is a six-bedroom, four-bathroom single-story home with barn access in rural area. There are no swimming pools or bodies of water of the premises. The current census is four (4). During the time of inspection, LPA Nestor conducted an inspection of the following areas: Entry: contains required postings including personal rights, AED, house rules and complaint procedures, rug, and entry to staff office. Staff Office: contains desk, chairs, secured cabinets for medications, First aid kit, nails polish, old batteries, sharps, and nail products. There is also a secured cabinet for client files and door leading to the garage. Continue on 809-C (Page 1) Garage: contains three (3) computers for school, couch, TV, and door leading to storage space. This area contains emergency food supplies, generator, refrigerator, additional storage shelves and door to building exterior. Water heater is located here. Left Hallway: contains locked storage closet that holds extra first aid, hygiene and cleaning supplies. Leads to three client bedrooms, linen cabinet, and staff hallway. Bedroom #1: Bedroom is occupied by one (1) client, (C4). It contains a twin bed, dressers, and adequate closet space. Bedroom #2: Bedroom is occupied by one (1) client, (C1). It contains a twin bed, dressers, ceiling fan and adequate closet space. Bedroom #3: Bedroom is occupied by one (1) client, (C2). It contains a twin bed, dressers and adequate closet space. Bedroom #4: Bedroom is occupied by one (1) client, (C3). It contains a twin bed, dressers, and clothing rack. Bedroom #5: Bedroom is vacant. It contains a twin bed, dressers, and clothing rack. Bedroom #6: Bedroom is vacant. It contains a twin bed, dressers, and clothing rack. Bathroom #1: contains hampers, functioning toilet, double sinks, and shower with running water. Bathroom #2: contains functioning toilet, sink and shower with running water. Bathroom #3: contains functioning toilet, double sinks and shower with running water. LPA tested the water temperature in this restroom that came out to be 112 degrees Fahrenheit. Staff Hallway: leads to two office spaces, laundry area and staff bathroom. Therapist Office: Used for individual/family therapy. It is equipped with soundproofing tiles, couch, chairs, desk and door leading to exterior. Continue on 809-C (Page 2) Medication Room/Manager's Office: contains cabinets for locked medications, medication fridge, desk and chairs. Laundry Space: contains washer and dryer, storage cabinets for laundry supplies. Living room: contains adequate seating for clients, TV, Bookcases, rug, fireplace that is inaccessible to clients. Switch is in locked office. Kitchen/Dining room: contains center island with three chairs, dishwasher, four burner stove and oven in operating condition, refrigerator, and microwave. Adjacent to the refrigerator is a walk-in pantry. Menu is posted on the fridge. There are perishables for up to two day and non-perishables for up to a week. Fridge operates at 37 degrees and the freezer at 0. Grocery shopping is done weekly. There is adequate dinnerware for clients and secured cabinets for daily cleaning supplies. There are sliding glass door that leads to exterior. Right Hallway: leads to three client bedrooms, bathroom, and sensory room. Breakout/Sensory Room: contains large bean bags, activities and soundproof tiles. Clients are accompanied by staff in this room. Exterior: opens to large green area, there are tables and chairs, small fountain, and tortoise enclosure. Left side of property houses solar panels and standing wells of the far side of property which ladder are locked and inaccessible to clients. 1/3 of Barn: contains office, half bathroom and group therapy space. It contains a TV, couch, table, chairs and secured activity cabinets. There is a door leading to exterior. LPA additional observations: There is a total of seven (7) fire extinguishers located throughout the facility and each facility vehicle is equipped with a fire extinguisher. The water temperature tested from bathroom #3 was 112 degrees Fahrenheit. LPA observed the licensee test the smoke/carbon monoxide alarms. The main water valve is located by the side of the garage. There are no cameras located on the facility property. Continue on 809-C (Page 3) Vehicles: LPA Nestor inspected two (2) facility vehicles in total. 1. Honda Odyssey (Grey) with current registration that expires in 5/2/2026. Insured by Nonprofit Insurance Alliance of California that expires 7/01/2025. VIN (last 4): 8966. 2. Honda Odyssey (Grey) with current registration that expires in 5/8/2025. Insured by Nonprofit Insurance Alliance of California that expires 7/1/2025. VIN (last 4): 9287. At the time of the inspection this vehicle is not in use. Licensee showed proof that the registration was renewed for the vehicle, and they are waiting for the registration to come in the mail. Vehicles are in good condition with no issues. Staff Interview: LPA Nestor conducted two (2) staff interview with S3and S2. Client Interview: LPA Nestor conducted two (2) client interviews with C3 and C1. Due to time constraints, LPA Nestor will return to complete the inspection. There were no deficiencies observed or cited at this time. An exit interview was conducted, and a copy of this report was emailed to the FA. (Page 4)

visit_type: Annual

met_with: Allison Jensen - Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On December 9, 2024 at 10am Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of conducting a Pre Licensing Inspection. LPA was met by Administrator, Tanya Grazziani and allowed into the facility. The facility is a Short Term Residential Program that services Six, 12-17yrs old, ambulatory clients. The home opens to a large living area that has a couch and a covered fireplace. There are two sliding glass doors opposite each other. One facing the back of the home is kept locked and inaccessible to clients. The other sliding glass door is going to be used as an entrance for clients and staff. There is a dining room table for clients and staff to eat. The kitchen area has a stove, air fryer and coffee maker all in good working conditions. There is a pantry with non-perishables. Next to the kitchen is the laundry room which contains a washer and dryer. Above the washer and dryer is two locked cabinets that will contain medication and sharps and detergent and cleaning supplies. There is an access door that leads to the front of the home. Bedroom #1 has two beds that have storage attached to them. There is a closet space for two clients. There is a desk and a tv attached to the wall. There is a full bathroom in good working condition. Bedroom #2 has two beds that have storage attached to them. There is a closet space for two clients. There is a desk and a tv attached to the wall. Bedroom #3 & #4 are single occupancy rooms equip with a bed with storage attached and closet space for one client. There is a desk and a tv attached to the walls of each room. The bathroom located in the hallway is a full bathroom in good working condition. This bathroom will be used by clients in rooms 2, 3 and 4. Cont. 809-C The backyard is a spacious, fenced in area for clients to use. There is a concrete area that will be used for private visits for clients. The front of the home has a detached two car garage. The administrator hopes to be able to use the garage as a recreation room and an office space. Note: Administrator has been advised to make mention of this to the Fire Inspector when they arrive for inspection. There is a deck which has been fenced in and inaccessible to clients. Note: The fenced in deck is sturdy, however some areas need repair which is the reason for the fence. LPA advised Administrator to add an opening due to the shut off valves being located inside the fenced area. The facility vehicle is a Mercedes Benz M350 with current registration and insurance until June 2025. LPA has advised Administrator, Tanya Grazziani that the current RFH license needs to be vacated before the STRTP licensing process can be completed by me. A grievance box needs to also be put in place inside the facility for the clients use. A first Aid kit needs to be placed in the facility vehicle and a thermometer and tweezers added to the kit inside the home. This concludes the pre licensing inspection.

visit_type: Prelicensing

met_with: Tanya Grazziani-Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On February 21, 2025 at 10am Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of observing the corrections from the initial pre licensing visit. LPA was met by Administrator, Tanya Grazziani and allowed into the home. The home is very clean and in order. The updates are as follows: LPA observed an empty home. The RFH license has been moved from the facility. A new fire inspection was conducted and the Administrator, Tanya Grazziani was advised to change the census from 6 clients to 5. A Grievance box is on the kitchen counter next to a new fire extinguisher. The sharps are in a locked cabinet above the washer and dryer. The 4th bedroom has been changed to an office. The closet contains a locked cabinet for medication. Room 3 is now single occupancy. On the outside of the home, the fencing around the deck has been completed and a locked opening has been added. The area will still be inaccessible to clients in care. The garage is will only be used as storage. There is a first aid kit in the facility vehicle and one in the home. All changes to the program statement have been submitted and are currently being reviewed. All corrections have been made and the home is prepared to receive clients. Nothing further to report at this time.


summary: Facility Evaluation

raw_content:
Narrative:
On September 24, 2025 at 11am Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of conducting Post Licensing inspection. LPA was met by Administrator, Tanya Grazziani and allowed into the home. The home is an STRTP equip to service 5 ambulatory clients 12-17 years of age, The facility is very clean and in order. The facility layout is as follows": The home opens to a large living area that has a couch and a covered fireplace. There are two sliding glass doors opposite each other. One facing the back of the home is kept locked and inaccessible to clients. The other sliding glass door is going to be used as an entrance for clients and staff. There is a dining room table for clients and staff to eat. The kitchen area has a stove, air fryer and coffee maker all in good working conditions. There is a pantry with non-perishables. Next to the kitchen is the laundry room which contains a washer and dryer. Above the washer and dryer is two locked cabinets that will contain medication and sharps and detergent and cleaning supplies. There is an access door that leads to the front of the home. Bedroom #1 has two beds that have storage attached to them. There is a closet space for two clients. There is a desk and a tv attached to the wall. There is a full bathroom in good working condition. Bedroom #2 has two beds that have storage attached to them. There is a closet space for two clients. There is a desk and a tv attached to the wall. Bedroom #3 1 single occupancy rooms equip with a bed with storage attached and closet space for one client. There is a desk and a tv attached to the walls of each room. The bathroom located in the hallway is a full bathroom in good working condition. This bathroom will be used by clients in rooms 2 & 3. Cont. 809-C There is a locked office in the hallway that will be used by staff. No clients are permitted in the office without staff presence. The backyard is a spacious, fenced in area for clients to use. There is a concrete area that will be used for private visits for clients. The front of the home has a detached two car garage. There is a deck which has been fenced in and inaccessible to clients. The facility vehicle is a Mercedes Benz M350 with current registration and insurance until June 2026. There still are no clients in care. The facility is ready to accept clients. No deficiencies were cited at the time of the visit.


summary: Facility Evaluation

raw_content:
Narrative:
On May 15, Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of conducting an Annual Inspection. LPA was met by Supervisor, William Alvarado and allowed into the home. The home is an STRTP equip to service 5 ambulatory clients 12-17 years of age, The facility is very clean and in order. The facility layout is as follows": The home opens to a large living area that has a couch and a covered fireplace. The fireplace is inoperable. There are two sliding glass doors opposite each other. One facing the back of the home is kept locked and inaccessible to clients. The other sliding glass door is going to be used as an entrance for clients and staff. There is a dining room table for clients and staff to eat. The kitchen area has a stove, air fryer and coffee maker all in good working conditions. There is a pantry with non-perishables. Next to the kitchen is the laundry room which contains a washer and dryer. Above the washer and dryer is two locked cabinets that will contain medication and sharps and detergent and cleaning supplies. There is an access door that leads to the front of the home. Bedroom #1 has two beds that have storage attached to them. There is a closet space for two clients. There is a desk and a tv attached to the wall. There is a full bathroom in good working condition. Bedroom #2 has two beds that have storage attached to them. There is a closet space for two clients. There is a desk and a tv attached to the wall. Bedroom #3 1 single occupancy rooms equip with a bed with storage attached and closet space for one client. There is a desk and a tv attached to the walls of each room. Cont. 809-C The bathroom located in the hallway is a full bathroom in good working condition. This bathroom will be used by clients in rooms 2 & 3. There is a locked office in the hallway that will be used by staff. No clients are permitted in the office without staff presence. Inside the office is a computer, copier, and a small refrigerator. There is a locked closet that has a locked file cabinet where client files and medication is kept. There is a two car garage that has bikes, basketballs, and other items for clients recreational use. There is a basketball hoop in front of the garage as well. The backyard is a spacious, fenced in area for clients to use. There is a concrete area that will be used for private visits for clients. The front of the home has a detached two car garage. There is a deck which has been fenced in and inaccessible to clients. The facility vehicle is a Mercedes Benz M350 with current registration and insurance until June 2026. LPA conducted one staff interview. Client refused to be interviewed. LPA reviewed one client file. LPA will return to review the staff and client files. LPA is aware that the provisional license expires May 19, 2026. LPA is in preparation process of approving the extension of the license. No deficiencies cited at the time of the visit.

met_with: William Alvarado-Supervisor


summary: Facility Evaluation

raw_content:
Narrative:
On May 19, 2026 at 10am Licensing Program Analyst (LPA) Donald Martin arrived at the above facility. The purpose of this visit is to continue the annual inspection of the facility. LPA met with Administrator, Tanya Grazziani and Board Member, Stacie Rodriguez an allowed into the facility. LPA will be reviewing the staff and client files and to document the progress of the facility contracts. Administrator, Tanya Grazziani stated that her Department of Mental Health (DMH) contract process started 3 weeks ago and conducts a meeting with DMH every Thursday. Administrator stated that C1 has since been linked to mental health services with Penny Lane. The facility DMH contact person is Tommy Hwang and his supervisor is Karina Vasuqez. Administrator stated that the accreditation process will begin June 1, 2026. Administrator has made contact and the contact person is Amanda Kostopolus (888) 281-6531 ex.7089. LPA reviewed files for S1, S2 and S3. S1 was not fingerprint cleared and was asked to leave the facility until clearance has been provided. S1 is also missing proof of college education. Administrator did provide a letter from an Attorney stating that S1 did graduate from a college in Guatemala, however documentation of this was destroyed in the Eaton fires. LPA will discuss the documentation with Licensing Program Manager (LPM) Enrique Hernandez. S1 is missing CPR/First Aid completion card. There is a health document in the file but proof of CPR/First Aid was not specifically notated. S1 requested the actual copy of the card today from the company. S1 is missing initial medical assessment and proof of TB test results. Cont 809-C S2 did have proof of TB test, but the medical exam itself was missing. S2 did not have proof of finger print clearance. S2 cannot work in the facility until clearances have been provided. S2 needs to provide education diploma/transcripts are acceptable as documentation. S3 is missing High School diploma and medical exam and TB test results. C1 is missing medical assessments. Client has been at the facility beyond 30 days. The MAR is filled out incorrectly. Staff needs to be trained on Medication distribution and documentation and system needs to be created to match the number of medication with the MAR. The facility is cited for the following: Client Medical Assessment (a) Except for licensees of ARFs , prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client, as specified in Section 80069(c), which enables the licensee to determine his/her ability to provide necessary health related services to the client. The assessment shall be used in developing the Needs and Services Plan. 80019 (e)(2) 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: (2) Obtain a California clearance or a criminal record exemption as required by the Department 80066 (a)(10)(11) Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g). (11) Tuberculosis test documents as specified in Section 80065(g). No staff are permitted to work in the facility until all medical documentation, CPR/First aid certifications have been obtained and medical/TB tests have been conducted and read by a physician. LPA will provide facility time to produce education documentation. A copy of this report is being left with the Administrator, Tayna Grazziani.


facility_name: TRINITY - APPLE VALLEY

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Additional confidential witnesses reported that there is a nutritionist who prepares monthly menus for the facility, however, the nutritionist may not always be aware of the preferred meal choices provided by the foster youth as the nutritionist works outside of the facility. During LPA's visit at the facility, the prepared meal for dinner was beef stew and there were no alternative meal options provided on the menu. During confidential interviews, it was disclosed that multiple youth preferred not to eat the beef stew and would have to prepare an alternative meal for themselves. Based on confidential interviews, the preponderance of evidence standard has been met and the Department has determined the allegation that the facility does not ensure the foster youth's nutritional needs are being met is substantiated. The facility is being cited for violation of the Title Regulations, Division 6, Chapter 1, Article 6, Section 80076(a)(1): Food Services. Based on confidential interviews, there are no prepared meal alternatives provided by the facility and the youth are instructed to prepare a meat or peanut butter/jelly sandwich as an alternative meal which does not provide adequate nutritional value and poses a potential health, safety, or personal rights risk to the youth in care. An exit interview was completed and a copy of this report, LIC 811 and appeal rights were provided. S1 denied ever having a sexual relationship with any of the foster youth and reported never being alone with the foster youth as S1 does not work directly in the dorms where the youth reside. Several additional confidential witnesses reported never observing S1 or any other staff interact in an inappropriate manner with foster youth at the facility other than what has been previously reported and investigated by CCL. Based on confidential interviews, the allegation that S1 sexually abused foster youth at the facility, may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was completed, and a copy of this report, appeal rights, and LIC 811 were provided to facility representative.

Investigation Findings:
13On July 21, 2021 at 11: AM, Licensing Program Analyst (LPA), Anastasia Flores, met with Trinity Apple Valley Campus Director, Elizabeth Tamoush, to deliver the finding for the above stated allegation. The investigation was conducted by LPA Wilson, which included a review of records for the facility and four foster youth. In addition, interviews were conducted with six staff, four foster youth, and three County Workers. On 3/18/21, LPA Wilson conducted a safety inspection at the facility and there were no immediate safety hazards observed. On 3/11/21, Community Care Licensing received information that foster youth placed at the facility are not being fed properly and there is never any food at the facility. On 3/18/21, LPA Wilson made a visit to the facility and observed adequate food stored inside of the cafeteria. LPA Wilson interviewed several confidential witnesses who reported that although there is food at the facility, the youth do not always want to eat the meals prepared by the cafeteria staff and are then instructed to prepare their own meat or peanut butter/jelly sandwich as an alternative. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Christina Barnes LICENSING EVALUATOR NAME: Anastasia Flores LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - APPLE VALLEYFACILITY NUMBER: VISIT DATE: 07/21/2021

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: Elizabeth Tamoush

complaint_status: unsubstantiated


raw_content:
Narrative:
Confidential interviews revealed that they did not seen C1 behave manic. Campus director (S1) stated that facility staff had thought that C1 was administered the wrong medication, but assistant campus director (S2) reviewed the Medication Administration Record (MAR) and found that there weren't any errors. Other confidential witnesses stated that they had not been informed that clients were administered the wrong medication. S2 stated that C1 was discontinued a medication and this is where the confusion arose. S2 stated that facility staff talked to C1's authorized representative and explained the situation. S2 stated that he recalled a time where C1 seemed down after receiving news about C1's family. S2 stated that C1 was never extremely emotional or manic. Another confidential witness stated that C1 was informed by facility staff that C1 was administered the wrong medication and that this caused C1 to behave emotional and manic. Based on confidential interviews and record reviews, the allegations that on April 1, 2021, C1 was administered the wrong medication by facility staff and C1's authorized representative was not notified of C1 having spiraled into an emotional and manic state, may have occurred, however are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Elizabeth Tamoush.

Investigation Findings:
13Licensing Program Analyst (LPA), Michael Almaraz, conducted an inspection and met with campus director, Elizabeth Tamoush, to issue the findings for the above stated allegations. The investigation was conducted by LPA Almaraz. LPA inspected the facility on April 27, 2021, at 3: PM and reviewed one client's records. During LPA inspection an interview was conducted with two facility staff. During the course of the investigation interviews were conducted with four additional facility staff and four of seven clients. Three of seven clients were unavailable for LPA interview. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - APPLE VALLEYFACILITY NUMBER: VISIT DATE: 07/28/2021

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


raw_content:
Narrative:
CSW1 stated that it was never disclosed to her that C1 was inappropriately touched by C2. CSW2 stated that she had never been informed that facility staff provided poor supervision. Other confidential witness stated that C1 was inappropriately touched on two separate occasions while in the day room. It was also disclosed that staff were nearby during the inappropriate touching, but staff was not paying attention to the clients when C2 touched C1's private area. Based on confidential interviews and record reviews, the allegation that lack of supervision resulted in C1 being inappropriately touched by C2 may have occurred, however, it is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Ronnie Elenez.

Investigation Findings:
13On April 28, 2022, at 9: AM Licensing Program Analyst (LPA) Michael Almaraz arrived at the facility and met with assistant campus director, Ronnie Elenez, to issue the finding for the above stated allegation. On September 16, 2021, at 2: PM, LPA Almaraz arrived at the facility to initiate the investigation and conducted a safety inspection. During the safety inspection, LPA interviewed two facility staff and reviewed client records. Additionally, LPA conducted interviews with six clients (C1, C2, C3, C4, C5, C6) listed on the confidential names list (LIC 811) dated April 28, 2022, two staff and two county social workers. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - APPLE VALLEYFACILITY NUMBER: VISIT DATE: 04/28/2022

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

met_with: Ronnie Elenez


summary: Complaint Investigation - Substantiated - 1 deficiency - 1 allegation

raw_content:
Narrative:
Based on confidential interviews and record review, the preponderance of evidence standard has been met and the Department has determined that C1 didn't take a medication as prescribed, therefore, the allegation is substantiated. The facility is being cited for violation of the Interim Licensing Standards, Chapter 7. Short Term Residential Therapeutic Program, Articles 1 through 10, Version Health Related Services 87075(c). An exit interview was conducted and a copy of this report along with the appeal rights were provided to Elizabeth Tamoush.

Investigation Findings:
13On May 5, 2022, at 9: AM Licensing Program Analyst (LPA), Michael Almaraz, arrived at the facility and met with campus director, Elizabeth Tamoush, to issue the finding for the above stated allegation. On April 28, 2022, 10: AM LPA Almaraz conducted a safety inspection at the facility. During the inspection LPA reviewed one client's records and conducted interviews with two clients and three staff. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - APPLE VALLEYFACILITY NUMBER: VISIT DATE: 05/05/2022

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

Deficiencies:
87075: Based on confidential interviews and record review the facility failed to administer...1
2
3
4
5
6
7Per facility campus director facility staff who administer medication will be retrained on ILS Health Related Services 87075.

complaint_status: SUBSTANTIATED

title: (c) Psychotropic medications shall be used only in accordance with the written directions of the physician prescribing the medication...This requirement was not met as evidenced by


raw_content:
Narrative:
Continued from LIC 9099 page On March 23, 2022, Community Care Licensing received a complaint alleging that lack of supervision resulted in inappropriate interactions between minors. During investigation, confidential interview stated that C1 was held down by other clients during horse play but denied that C1 was touched inappropriately by other clients. Confidential interview added that C1 did not feel uncomfortable when being held down because C1 and other clients were joking around. Other confidential interviews denied witnessing C1 being held down or touched inappropriately by other clients. Confidential interviews also denied being touched inappropriately at the STRTP and expressed feeling safe. Other confidential interviews stated that C1 was involved in physical altercations with other clients at the STRTP. A confidential interview stated that sometimes bullying occurs in client dorms and stated witnessing an altercation involving C1, however, confidential interview denied that C1 was held down or touched inappropriately by other clients. Other confidential interviews denied knowing that C1 was held down or touched inappropriately by other clients while placed at the STRTP. Other Confidential interviews reported that clients are supervised by staff at the STRTP. Confidential interviews further stated that staff position themselves in the same area where clients are located at and when clients are in their dorms staff check on clients periodically. LPA received inconsistent information to determine if there was a lack of supervision resulted in inappropriate interactions. Based on the confidential interviews, the allegation that lack of supervision resulted in inappropriate interactions between minors, may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Trinity Apple Valley STRTP Campus Director, Elizabeth Tamoush.

Investigation Findings:
13On December 28, 2022, at 9: AM, Licensing Program Analyst (LPA) Cynthia Urena, met with Trinity Apple Valley Short Term Residential Therapeutic Program (STRTP) Campus Director, Elizabeth Tamoush to deliver the investigative finding for the above stated allegation. On March 30, 2022, at 09: AM, Licensing Program Analyst (LPA) Michael Almaraz initiated the investigation at the STRTP. LPA Almaraz conducted a health and safety inspection, and no immediate deficiencies were observed. LPA Almaraz reviewed two client files and conducted interviews with one staff member staff 1 (S1), and two clients (C3, C4). Additionally, LPA Almaraz interviewed client 1 (C1). On December 15, 2022, at 9: AM, LPA Cynthia Urena, interviewed client 5 (C5) and on Decembe19, 2022, LPA Urena interviewed staff 2 (S2). Continued on LIC C page 2... UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: TRINITY - APPLE VALLEYFACILITY NUMBER: VISIT DATE: 12/28/2022

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

met_with: Campus Director, Elizabeth Tamoush


raw_content:
Narrative:
**Continued from LIC C page 1** In regard to the allegation that staff are not following doctor's order for resident in care, a confidential interview maintained that C1 had a follow-up medical appointment and was prescribed medication, however, staff did not transport C1 to the medical appointment or filled C1's medication as directed by a doctor. Other confidential interviews stated not being aware that staff did not refill C1's medication as directed. A confidential interview stated C1 did not inform staff that a medication needed to be refilled. Another confidential interview stated having knowledge of a prescription medication refill for C1 but was not aware of the reason why the medication was not refilled. Other confidential interviews stated that staff provided medication as needed. A confidential interview stated recalling a time when their medication ran out for a few days. Another confidential interview reported not having issues in obtaining prescription medication at the STRTP. Regarding the allegation that staff do not treat residents with dignity and respect, a confidential interview stated after a verbal altercation with a staff member, another staff member was heard using profanity when speaking to C1. Other confidential interviews stated that staff treat clients with dignity and respect and denied being disrespected by staff. Another confidential interview witnessed staff using a firm voice when clients were not listening. Other confidential interviews denied witnessing staff behaving disrespectful towards clients. Regarding the allegation that staff do not take residents on scheduled outings, confidential interviews stated staff shortage have caused client outings to be cancelled. Other confidential interviews stated that some clients get to participate in outings while others do not. A confidential interview stated that some outings and activities are earned, and outings can be revoked due to client behaviors. Another confidential interview stated clients are taken on outings and added that when there is staff shortage program staff find other alternatives while considering client safety. Regarding the allegation that the facility is in disrepair, it was specified that the facility air conditioner (AC) has not worked for over five years. A confidential interview reported witnessing the air conditioner undergoing maintenance. **Continued on LIC C page 3** ** Continued from LIC C page 2** Confidential interviewed continued stating that the STRTP has issues with the air conditioning every year during summer. Other confidential interviews reported that program staff purchased portable AC units for clients while the air conditioner was being repaired. Other confidential interviews reported that client dorms were hot despite having portable AC units. Based on the confidential interviews, the allegations that staff were not following doctor's order for C1, staff did not treat clients with dignity and respect, staff did not take clients on scheduled outings, and facility was in disrepair may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Trinity Apple Valley STRTP Campus Director, Elizabeth Tamoush.

Investigation Findings:
On Wednesday January 18, 2023, at 11: AM, Licensing Program Analyst (LPA) Cynthia Urena met with Trinity Apple Valley Short Term Residential Therapeutic Program (STRTP) Campus Director, Elizabeth Tamoush to deliver the investigative findings for the above stated allegations. On June 17, 2022, at 10: AM, Licensing Program Analyst (LPA) Michael Almaraz initiated the investigation at the STRTP. LPA Almaraz conducted a health and safety inspection, and no immediate deficiencies were observed. LPA Almaraz reviewed two client files and conducted interviews with three staff (S1, S2 and S3), and three clients (C1, C2 and C3). On June 14, 2022, Community Care Licensing received a complaint alleging that staff are not following doctor's order for resident in care, staff do not treat residents with dignity and respect, staff do not take residents on scheduled outings, and facility is in disrepair. **Continued on LIC C page 2** UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: TRINITY - APPLE VALLEYFACILITY NUMBER: VISIT DATE: 01/18/2023

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


raw_content:
Narrative:
** Continued from LIC C page 3** Based on observations, record review, and confidential interviews, the allegation that staff do not provide an adequate amount of hygiene supplies, facility has inadequate staffing, clients had access to cleaning supply cabinet while in care, clients rooms are not properly maintained, clients are not properly groomed while in care, staff did not prevent C1 from causing self-harm, staff do not provide adequate food services for clients, and staff do not address clients clothing needs while in care, may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Trinity Apple Valley STRTP, Campus Director, Elizabeth Tamoush **Continued from LIC C page 2** A confidential interview stated that staff dock point from clients whose rooms are not cleaned. Confidential interview continued stating that there were times when staff clean client's rooms when clients were not in rooms. Other confidential interviews stated that program staff educate clients on the importance of cleanliness and grooming. Regarding the allegation that staff did not prevent C1 from causing self-harm, confidential interviews stated staff reacted immediately when clients were exhibiting self-harming behaviors. A confidential interview stated witnessing staff providing prevention care to C1. Another confidential interview stated that staff provided C4 with the adequate services when C4 exhibited self-harming behaviors. Other confidential interviews reported feeling safe in placement. Regarding the allegation that staff did not provide adequate food services for clients, confidential interviews stated the food at the facility was good, and on weekends staff purchase fast food for all clients. Other confidential interviews denied that clients have become ill from the food provided at the facility. Confidential interviews further stated that there has not been issue with food at the facility. Other confidential interviews reported that clients enjoy when staff purchase fast food on the weekends. Another confidential interview stated disliking the cafeteria food that is provided at the facility and continued stating enjoying when staff purchase pizza for clients. In regard to the allegation that staff did not address the minors clothing needs while in care, a confidential interview stated that the STRTP provides a monthly clothing allowance to all clients in placement. Confidential interview continued stating clients are provided $83.00 of clothing allowance and have the option to accumulate $240.00 on a quarterly basis. Confidential interview also stated that clients are taken shopping by program staff. Other confidential interviews stated not having issues with clothing allowance at the facility. Confidential interviews continued stating clients have clothes and are provided a monthly clothing allowance. **Continued on LIC C page 4** **Continued from LIC 9099 page 1** adequate amount of hygiene supplies, facility has inadequate staffing, clients had access to cleaning supply cabinet while in care, clients rooms are not properly maintained, clients are not properly groomed while in care, staff did not prevent Client 1 (C1) from causing self-harm, staff do not provide adequate food services for clients, staff do not address clients clothing Regarding the allegation staff do not provide an adequate amount of hygiene supplies, confidential interviews stated having access to hygiene products. Confidential interviews added that staff provide clients with hygiene products when needed. Another confidential interview stated that hygiene products are purchased when there is a shortage on supplies. Confidential interview continued stating not knowing how often staff purchase hygiene supplies. Additional a confidential stated a request was made for body lotion multiple times and they were not sure when the lotion was provided. In regard to the allegation facility has inadequate staffing, confidential interviews stated that due to COVID-19, there has been staff shortage. The confidential interview denied that the facility was out of ratio. A confidential interview stated that on weekends, there were two or three staff on duty. Confidential interview further stated staff are on call and available to report to the STRTP as needed. Other confidential interviews stated clients are supervised by staff accordingly and denied staff shortage. Another confidential interview disclosed that staff were on their cell phones when supervising clients and worries about clients received appropriate supervision. Regarding the allegation that clients had access to cleaning supply cabinet while in care, confidential interviews denied having access to chemicals while in care. Other confidential interviews stated cabinets that store the facility's chemicals remains locked and inaccessible to clients. Other confidential interviews denied witnessing the chemical cabinet open and accessible to clients. Regarding the allegations that client's rooms were not properly maintained, and minors were not properly groomed while in care. all confidential interviews stated staff encourage clients to maintain rooms clean, and to groom daily, however, not all clients follow staff requests. **Continued on LIC C page 3**

Investigation Findings:
13On January 25, 2023, at 10: AM, Licensing Program Analysts (LPAs) Cynthia Urena and Karen Beal met with Trinity Apple Valley Short Term Residential Therapeutic Program (STRTP) Campus Director, Elizabeth Tamoush to deliver the investigative finding for the above stated allegations. On February 9, 2022, at 9: AM, Licensing Program Analyst (LPA) Michael Almaraz initiated the investigation at the STRTP. LPA Michael Almaraz conducted a safety inspection of the facility, and no immediate deficiencies were observed. LPA Almaraz reviewed two client files and conducted interviews with two staff member staff (S1, S2) and three clients (C2, C3, C4). On December 28, 2022, at 10: AM, LPA Cynthia Urena conducted a walkthrough of the facility with S2. On February 04, 2022, Community Care Licensing received a complaint alleging that staff do not provide an **Continued on LIC C page 2** UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: TRINITY - APPLE VALLEYFACILITY NUMBER: VISIT DATE: 01/25/2023

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


raw_content:
Narrative:
County social workers did not have concerns of lack of supervision occurring at the facility. County social worker (CSW) stated that he was informed that C1 had inappropriate photos on a cellular phone. Other confidential witness informed LPA that they had seen C1 using a cellular phone while at the facility. Based on confidential interviews and records review, the allegation that due to lack of supervision C1 had inappropriate photos on a cellular phone may have occurred, however, it is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Elizabeth Tamoush.

Investigation Findings:
13On June 15, 2023, at 1: PM Licensing Program Analyst (LPA) Michael Almaraz arrived at the facility and met with Campus Director, Elizabeth Tamoush, to issue the finding for the above stated allegation. This complaint investigation was conducted by LPA Almaraz. On March 2, 2023, at 10: AM, LPA arrived at the facility to initiate the investigation, conducted a safety inspection; reviewed one client file, interviewed one client and interviewed three staff. During the course of the investigation, LPA Almaraz conducted three staff interviews, six client interviews (C1, C2, C3, C4, C5, and C6) see confidential names list (LIC 811) dated June 15, 2023 and two county worker interviews. On February 21, 2023, the Department received a complaint that alleged minor had access to inappropriate pictures on their phone while in care. It was specifically alleged that due to lack of supervision, C1 had inappropriate photos on a cellular phone. Confidential witness' interviews revealed that staff provided appropriate supervision to clients. Furthermore, it was revealed that C1 was not seen in possession of a cellular phone while at the facility. (continued on page 2...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - APPLE VALLEYFACILITY NUMBER: VISIT DATE: 06/15/2023

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


facility_name: TRINITY - EL MONTE

raw_content:
Narrative:
During interviews, case manager stated there was communication with the client, but stated there was a day that the internet was not working and they still had cell phones available for communication. Client denied the allegations. Based on interviews and records reviewed there was no corroborating information to substantiate the allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the above allegations did or did not happen, therefore, the above allegations are being closed unsubstantiated. No deficiencies were cited during this inspection.

Investigation Findings:
13On 07/22/2021 at 2:30PM, Licensing Program Analyst (LPA) Pedro Ramos conducted a follow up complaint inspection to the above group home. The purpose of the inspection was to deliver findings for the above complaint allegations. LPA spoke with Jaime Acosta, Administrator during the inspection. During the course of this investigation, LPA conducted telephone interviews with the facility Administrator on 3/26/21, Case Manager and one client on 03/26/21. (refer to Confidential Names LIC 811 dated 07/22/2021). LPA reviewed and obtained the following documents; email documents, Needs and Services Plan and Special Incident Report. It was alleged minor did not have access to telephone while in care and staff demonstrated inappropriate form of punishment. The Administrator denied the allegations and disclosed that the facility did have a problem with their internet service, but the clients did have access to phones. He also stated the clinet was moved to a different cottage due to safety concerns due to an incident with another client. He stated it was a safety protocol they follow. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Pedro Ramos 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: TRINITY - EL MONTEFACILITY NUMBER: VISIT DATE: 07/22/2021

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

met_with: Jaime Acosta, Administrator


raw_content:
Narrative:
The following allegations were made against the facility: Minors have access to illegal drugs while in care; minors are not being properly fed while in care; staff are not properly supervising the minors while in care; staff are not properly maintaining the facility; staff are not monitoring a minor's change in medical condition; staff are not addressing a minor's hygiene needs; facility is in disrepair, and staff interfered with CCL's visit to the facility. An unannounced inspection of the entire facility was conducted and each room was checked. Each facility room and the overall condition of the property were observed to be well maintained. The kitchen was fully stocked with food. Facility staff were following Covid-19 health and safety protocols with the use of masks, social distancing, and the facility had posters throughout the facility reminding staff and clients to follow Covid-19 safety protocols. The facility also had stock of sanitizers and personal protective equipment. Confidential statements obtained could not corroborate that clients had access to illicit drugs at the facility. The facility administrator also stated that a drug-sniffing dog used by law enforcement was also employed by the facility which did not result in discovery of illicit drugs. Confidential statements obtained also could not corroborate that clients were neglected by the facility regarding their hygiene needs, food, health and safety. There were ample supply of food and hygiene products at the facility. There were facility staff always present in each of the building that house the clients. Confidential statements obtained also could not corroborate that Community Care Licensing staff were purposely delayed in conducting their duties at the facility during unannounced inspections. Based on the information gathered, although the allegations may have happened or is valid, the preponderance of evidence to prove the allegations was not met, therefore the allegations are unsubstantiated. A copy of this report, Confidential Names Form and Appeal Rights were provided to the facility representative. There were no deficiencies cited during this inspection.

Investigation Findings:
13On August 19, 2021 at 9: AM, Licensing Program Analyst (LPA) Joshua Rarela conducted a follow-up inspection to deliver the findings of a complaint investigation concerning the allegations above. LPA Rarela discussed the findings with the facility representative named above. During the course of the investigation, LPA Rarela interview facility clients and facility staff on 2/12/21 (see Confidential Names Form dated August 19, 2021). An unannounced inspection of the facility was also conducted the same day as some of the allegations required in-person inspection to evaluate its merit. LPA also reviewed documents on 2/12/21 including placing agency records, facility repair work order documents, facility personnel and client roster and facility incident reports. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Joshua Rarela 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: TRINITY - EL MONTEFACILITY NUMBER: VISIT DATE: 08/19/2021

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

met_with: Jaime Acosta, Assistant Director


raw_content:
Narrative:
It was reported S1 had a history of yelling at C1. S1 denied the allegation. Statements obtained from interviews conducted with staff revealed S1 speaks firmly to clients in care but does not yell. Staff denied that S1 and C1 had a history of yelling at each other. Statements obtained from confidential interview conducted provided conflicting statements regarding S1 yelling at clients. Two of the clients interviewed reported S1 does not yell at clients, one reported S1 yells at clients for minor incidents and one client reported he has not met S1. It was reported S1 told C1 he was getting sexual with her when he pressed his body against hers while he attempted to push past her. S1 denied the allegation and reported saying "This is inappropriate". Statements obtained from confidential interviews conducted and interviews with staff revealed there were no witnesses to the reported alleged comments made by S1. Based on information obtained through interviews conducted and records reviewed the allegations were Unsubstantiated. An unsubstantiated finding means that although the allegations may have occurred or are valid, the standard of the preponderance of evidence was not met. Exit interview conducted and a copy of this report was provided to the facility representative mentioned above.

Investigation Findings:
13On 9/22/21 at 1: PM, Licensing Program Analyst (LPA) Christopher Larios conducted a follow up complaint inspection and met with Administrator Jaime Acosta. The purpose of the inspection was to deliver findings for the above-mentioned complaint allegations. During the course of the investigation LPA Larios conducted a records review on 3/25/21 and obtained staff contact information, special incident reports, clients needs and services plans and staff (S1) suspension report. LPA Larios conducted interviews with one facility staff and one Administrator (AD) on 3/26/21, four facility staff on 9/21/21 and four clients on 9/21/21. LPA Larios attempted to interview one Probation Officer (PO) but, phone contacts were not returned. One client (C1) declined to provide a statement regarding the reported alleged incident. (Reference Confidential Names list LIC811 dated 9/22/21) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Deborah A Santos LICENSING EVALUATOR NAME: Christopher Larios 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: TRINITY - EL MONTEFACILITY NUMBER: VISIT DATE: 09/22/2021

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

met_with: Jaime Acosta


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
It was reported S1 mishandled C1 by pushing him. S1 reported she placed her hands on C1's chest to create separation when he attempted to get past her and pushed against her with his body. S1 denied she pushed C1 because, although she used her hands to create separation, it was non-violent. Statements obtained from an interview conducted with AD indicated S1 was suspended as a result of the incident. The suspension was due to reviewing video footage of the incident and Administrators determining C1 was pushed by S1. Based on information obtained from interviews conducted and records reviewed the allegation was Substantiated. C1's personal rights were not afforded as require by the Interim Licensing Standards (ILS) Ver. 3. Sec. 87072(d)(11). The allegation is valid because the standard of the preponderance of evidence has been met. Facility cited for violation of Interim Licensing Standards (ILS) Ver. 3. Sec. 87072(d)(11): Personal Rights. Statements obtained from interviews conducted corroborated the allegation that a staff mishandled a minor in care. Exit interview conducted and a copy of this report along with a LIC9099D and LIC811 were provided to the facility representative. Appeals rights were discussed and provided.

Investigation Findings:
13On 9/22/21 at 1: PM, Licensing Program Analyst (LPA) Christopher Larios conducted a follow up complaint inspection and met with Administrator Jaime Acosta. The purpose of the inspection was to deliver findings for the above-mentioned complaint allegation. During the course of the investigation LPA Larios conducted a records review on 3/25/21 and obtained staff contact information, special incident reports, clients needs and services plans and staff (S1) suspension report. LPA Larios conducted interviews with one facility staff and one Administrator (AD) on 3/26/21, four facility staff on 9/21/21 and four clients on 9/21/21. LPA Larios attempted to interview one Probation Officer (PO) but, phone contacts were not returned. One client (C1) declined to provide a statement regarding the reported alleged incident. (Reference Confidential Names list LIC811 dated 9/22/21) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Deborah A Santos LICENSING EVALUATOR NAME: Christopher Larios 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: TRINITY - EL MONTEFACILITY NUMBER: VISIT DATE: 09/22/2021

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


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) T. Davis and LPA Juliet Robles went to Trinity - El Monte on September 14, 2021 at 8:45am for the purposes of a joint unannounced Required Annual inspection. LPAs met with Jaime Acosta, Assistant Director (AD), and together they toured the facility both inside and outside. The facility is licensed to serve forty-three (43) male clients ages 11-17 years old. The facility is a Short Term Residential Therapeutic Program (STRTP) and is located in a residential neighborhood. It also provides services to Non-Minor Dependents (NMD) as well. The campus consists of three individual dorms (Aztecs, Trojans, and Golden Bears) for client placement. There are five clients presently at the facility and all five reside in the Aztecs dorm. Sharp knives, cleaning supplies, and medications are kept locked in areas inaccessible to clients. The bedrooms in each dorm contained twin beds, dressers, and closet space. Smoke alarms were operable throughout the facility. There is adequate seating in the common areas of each dorm. All rules and regulations were posted at the facility. LPAs observed a weight lifting area, ping pong table, basketball court, several board games, computers, reference materials and books at the facility for client use. LPAs also observed ample food supply at the facility. LPAs observed the outdoor areas to be free of debris and hazards. The last earthquake drill occurred on July 07, 2021 at 8:55am. Bulletin boards were posted in each dorm that contained personal rights information, facility license, emergency disaster plan information, ombudsman information, foster youth rights, disaster plan information, accreditation, and other important information. The last fire drill was held on August 18, 2021 at 5:41pm. The last active shooter drill (lockdown) was held on July 28, 2021 at 6:36pm. The facility has nine available vans for client transportation. LPAs obtained a current copy of the facility's staff roster (LIC500) and a client roster. LPA also obtained a copy of the minutes of the most recent Board of Director's meeting that was held on June 11, 2021. Two clients and two staff were interviewed.


facility_name: TRINITY - YUCAIPA

raw_content:
Narrative:
denied observing this. Confidential interviews reported that S1 had a good relationship with C1. Confidential interviews reported that S1 has been observed taking walks on campus with C1 and was reported to have been in C1's room on multiple occasions. Confidential interviews disclosed that staff had documented discussions with S1 regarding boundaries with the residents. Confidential interviews reported that C1 and S1 denied being in a relationship with one another. Confidential interviews reported that C2 was unsure how often C1 and S1 observed inappropriate behaviors. Other confidential interviews disclosed S1 had never been in an inappropriate relationship with C1. LPA received inconsistent information regarding the allegation. Based on confidential interviews during this investigation, the allegation that conduct inimical: facility staff is engaging in an inappropriate relationship with a minor in care, may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. Exit interviewed conducted. A copy of this report and appeal rights were given and explained to Jason Mayo.

Investigation Findings:
13On September 13, 2021 at 10:41am, Licensing Program Analyst (LPA), Cheraki Davis met with Jason Mayo, Short Term Residential Therapeutic Program (STRTP) Assistant Director to deliver the finding for the above complaint allegation. On 06/02/2021 at 10:30am, LPA conducted a safety inspection and no immediate safety hazards were observed. The investigation was conducted by Special Investigator Lori Wood of the Community Care Licensing (CCL) Investigations Bureau. Investigation included interviews with Inyo County Probation Officer, Campus Director, Assistant Director, Team Administrator Supervisor, Clinical Coordinator, one facility staff, Supervisor of Spartan Dorm, one former employee, and two clients (C1 & C2). San Bernardino County Sheriff's Department report was reviewed. On May 26, 2021, Community Care Licensing received an allegation which stated conduct inimical: facility staff (S1) is engaging in an inappropriate relationship with a minor (C1) in care. It was reported that a staff (S1) makes out with one of the youths (C1) that resides in one of the dorms. Confidential interviews reported that C2 observed C1 hug S1 at least once. Confidential interviews reported that S1 would "kiss" C1, but C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Cheraki Davis LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - YUCAIPAFACILITY NUMBER: VISIT DATE: 09/13/2021

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

met_with: Jason Mayo, Assistant Director


raw_content:
Narrative:
Community Care Licensing received information on July 20, 2021 alleging that the facility was not administering medications as prescribed. It was specified that an unknown client was given old medication from an old psychiatrist. During the investigation, confidential interviews stated not being aware of C1 and other clients being taken off a medication. Confidential interviews stated C1 and other clients refused medication at times and was encouraged to take the medication. Another confidential interview stated that they were not aware of change in medication for C1 or other clients. Other interviews did not have any information regarding the administration of medications at the facility. C1's Probation Officer stated C1 did not disclose any medication issues while placed at the facility. Based on confidential interviews, the allegation that the facility was not administering medications as prescribed, may have occurred, however, it is not supported or proven by evidence. Therefore, this allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Assistant Director Jason Mayo.

Investigation Findings:
13On March 4, 2022 at 11:50am, Licensing Program Analyst (LPA) Adaleyci Caballero met with Trinity Yucaipa Assistant Director Jason Mayo to deliver the investigative finding for the above stated allegation involving clients in the facility. On July 2021 at 10:40AM, LPA Michael Almaraz initiated the investigation at the facility and interviewed four staff and three of four clients (C1, C2, and C3). Lpa a. Caballero was unable to obtain C4 contact information and LPA was unable to locate C4 at this time. Additionally, LPA Caballero did not receive a response from C4's County Social worker. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Adaleyci Caballero LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - YUCAIPAFACILITY NUMBER: VISIT DATE: 03/04/2022

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

met_with: Assistant Director- Jason Mayo


raw_content:
Narrative:
OHI stated that OHI was informed that C1 and C2 engaged in a physical altercation and staff immediately intervened. CSW stated that she was informed that C1 would leave the facility and staff would try to convince C1 to stay but C1 would ignore staff. Confidential witnesses stated that anytime that clients would go out of area in an attempt to leave the facility, the facility staff follow the clients attempting to get them to stay. Confidential witnesses disclosed that staff supervise the clients appropriately. Confidential witnesses stated that C1 and C2 were involved in a physical altercation and staff immediately intervened. Other confidential witnesses stated that clients would leave area without the staff noticing and C2 was not supervised correctly allowing C2 to assault C1. LPA received inconsistent information regarding the allegations. Based on confidential interviews and record review, the allegations that due to lack of supervision facility staff did not prevent C1 from leaving the group home and C1 was physically assaulted by C2 while in care may have occurred, however, are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Jason Mayo.

Investigation Findings:
13On March 18, 2022, Licensing Program Analyst (LPA), Michael Almaraz, arrived at the facility and met with assistant campus director, Jason Mayo, to issue the finding for the above stated allegations. On July 21, 2021, at 10: AM LPA Almaraz conducted a safety inspection at the facility. During the inspection, LPA reviewed children's records and conducted interviews with four clients (C3, C4, C5, C6) and four staff. Additionally, LPA conducted an interview with one client (C1), one county social worker (CSW), and Riverside County Out of Home Investigator (OHI). One client (C2) was unavailable for LPA interview. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - YUCAIPAFACILITY NUMBER: VISIT DATE: 03/18/2022

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

met_with: Jason Mayo


raw_content:
Narrative:
Continued from LIC C On December 7, 2022, LPA Cynthia Urena, attempted to conduct an interviewed with two staff members (S1, and S3) however, LPA was unable to contact both S1 and S3. On December 8, 2022, at 11: AM, LPA Urena conducted and interview with staff 4 (S4). In regard to the allegation that staff handled minor in a rough manner, a confidential interview stated that there was an altercation between C1 and C2 that resulted in staff handling C1 in a rough manor causing C1 to have shoulder pain. Other confidential interviews denied being handled in a rough manner by staff. Confidential interviews continued stating not witnessing C1 being handled in a rough manner by staff. Other confidential interviews stated that C1 has temperament problems and other behaviors, however, the interviews denied that C1 was handled in a rough manner. Regarding the allegation that staff are discriminating against minor, a confidential interview stated S1 was picking on C1 and was blaming C1 for the issues occurring among clients resulting in C1 feeling discriminated. Confidential interview further stated liking other staff, however, felt that S1 was favoring C2. Another confidential interview stated not liking the placement and feeling unsafe due to S1 and C2 being good friends. Confidential interview further stated that S1 allows C2 to get away with things that are not allowed. Confidential interview also stated that S1 overlooks C2's behaviors and C2 is not reprimanded for picking on other clients. Another confidential interview stated not witnessing S1 or staff discriminating against other clients. Confidential interview further stated that staff favor C1 more than other clients. Confidential interviews denied that staff are discriminating against minors. Based on the confidential interviews, the allegations that staff handled C1 in a rough manner, and staff are discriminating against C1, may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Trinity Yucaipa STRTP, Campus Director, Teresa Valles.

Investigation Findings:
13On December 12, 2022, at 9: AM, Licensing Program Analyst (LPA) Cynthia Urena, met with Trinity Yucaipa Short Term Residential Therapeutic Program (STRTP) Campus Director, Teresa Valles, to deliver the investigative finding for the above stated allegations. On March 14, 2022, Community Care Licensing received a complaint alleging that staff handled minor in a rough manner, and staff are discriminating against minor. On March 18, 2022, at 2: PM, Licensing Program Analyst (LPA) Michael Almaraz, initiated the investigation at the STRTP. LPA Almaraz conducted a health and safety inspection, and no immediate deficiencies were observed. LPA Almaraz reviewed client's files and conducted interviews with one staff member staff 2 (S2) and two clients (C1, C2). On March 30, 2022, LPA Almaraz conducted an interview with client 3 (C3). Continued on LIC C page 2... UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: TRINITY - YUCAIPAFACILITY NUMBER: VISIT DATE: 12/12/2022

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

met_with: Campus Director, Teresa Valles


raw_content:
Narrative:
Other confidential witnesses stated that S1 and C1 were involved in a verbal altercation, but they did not witness S1 slapping C1. Furthermore, a confidential interview denied that S1 was physically aggressive toward C1 and added that it was C1 who was attempting to hit S1. LPA received conflicting information throughout the investigation. Based on confidential interviews and record review, the allegation that S1 slapped C1 may have occurred, however, it is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Jason Mayo.

Investigation Findings:
13On February 16, 2023, at 10: AM Licensing Program Analyst (LPA) Michael Almaraz, arrived at the facility and met with Trinity Yucaipa Assistant Campus Director, Jason Mayo, to issue the finding for the above stated allegation. On September 22, 2022, at 9: AM, LPA Almaraz arrived at the facility to initiate the investigation and conducted a safety inspection. During the safety inspection, LPA reviewed one client's records, interviewed three facility staff, and interviewed one client (C1) listed on the confidential names list (LIC 811) dated February 16, 2023. Additionally, LPA conducted two staff interviews. On September 19, 2022, the Department received a complaint that alleged staff #1 (S1) slapped C1. During the investigation, a confidential witness disclosed that on September 15, 2022, C1 and S1 were involved in a verbal altercation and S1 slapped C1 on the face. Confidential witnesses added that S1 was upset and attacked C1, but another staff was able to intervene to prevent a physical altercation between S1 and C1. Another confidential witness stated that C1 had an injury on C1's face after the dispute with S1, but it was indicated that C1 had self injurious behaviors. (continued on page 2...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - YUCAIPAFACILITY NUMBER: VISIT DATE: 02/16/2023

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


raw_content:
Narrative:
Confidential witness' interviews revealed that staff provided appropriate supervision to clients. Furthermore, it was revealed that room visiting was not allowed to prevent clients from stealing from one another. Additional confidential witnesses stated that C1 walked into C3 and C4's bedroom then C3 and C4 fought with C1. It was revealed to LPA that staff attempted to redirect C1 from entering C3 and C4's bedroom but C1 ignored staff. LPA received other information that lack of supervision led to C1 being beaten up. Regarding the allegation that C1's belongings were stolen confidential witnesses stated that C1 did not have a personal cellular phone while placed at the facility and the phone that was reported as being C1's was the facility phone. Other confidential witnesses stated that C1 had his own personal phone that was stolen at the facility. LPA received inconsistent information regarding the allegations. Based on confidential interviews and record reviews, the allegations that due to lack of supervision C1 was beaten up by two clients and C1's cellular phone was stolen at the facility may have occurred, however, they are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Teresa Valles.

Investigation Findings:
13On May 17, 2023, at 12: PM Licensing Program Analyst (LPA), Michael Almaraz, arrived at the facility and met with Campus Director, Teresa Valles, to issue the finding for the above stated allegations. This complaint investigation was jointly conducted by LPA Cynthia Urena and Michael Almaraz. On October 5, 2022, at 9: AM, LPA Urena arrived at the facility to initiate the investigation, review staff and client files and conducted a safety inspection. Additionally, LPA Almaraz conducted six staff interviews, five client (C2, C3, C5, C6, C7) interviews see confidential names list (LIC 811) date May 17, 2023, and an additional confidential witness interview. Two clients could not participate in LPA interview due LPA Almaraz being unable to locate them. On September 26, 2022, the Department received a complaint that alleged minor was physically abused by other minors due to lack of supervision and minor's belonging was stolen. It was specifically alleged that due to lack of supervision client #1 (C1) was beaten up by two clients and C1's cellular phone was stolen at the facility. (continued on page 2...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - YUCAIPAFACILITY NUMBER: VISIT DATE: 05/17/2023

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

met_with: Campus Director Teresa Valles


raw_content:
Narrative:
C1 and C7 engaged in sexual activity due to lack of supervision by staff. Confidential witness' interviews revealed that they had never seen or heard S1 requesting sexual favors from clients. An additional confidential witness interview denied that S1 had requested sexual favors from clients. PO stated that she was not informed of inappropriate interactions between a staff and clients. Other confidential witness stated that S1 would offer clients vape pens and drugs in exchange for allowing S1 to touch clients in a sexual manner. Regarding the allegation that S1 offered vape pens to clients. Confidential witness denied that S1 provided clients with vape pens or any other contraband. Furthermore, additional confidential witnesses stated that they had not seen or been informed of S1 or any other staff providing clients with vape pens or contraband. PO stated that she was not informed of staff providing clients with contraband. Other confidential witnesses maintained that S1 had provided C1 and C4 with vape pens and drugs. In regard to the allegation that lack of supervision led to C1 and C7 engaging in inappropriate sexual behavior while in care. LPA was informed by confidential witnesses that they had not seen any sexual inappropriateness amongst clients occurring at the facility. Other confidential witnesses stated that they had heard that C7 engaged with clients in an inappropriate sexual manner. PO stated that she did not suspect of lack of supervision resulting inappropriate sexual behaviors. Based on confidential interviews and record reviews, the allegations that S1 would offer C1 vape pens in exchange for allowing S1 to touch C1's private areas, S1 provided vape pens to clients, and C1 and C7 engaged in sexual activity due to lack of supervision by staff may have occurred, however, they are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Jason Mayo.

Investigation Findings:
13On June 21, 2023, at 11: AM Licensing Program Analyst (LPA) Michael Almaraz arrived at the facility and met with Assistant Campus Director, Jason Mayo, to issue the finding for the above stated allegations. This complaint investigation was conducted by LPA Michael Almaraz. On March 1, 2023, 10: AM, LPA arrived at the facility to initiate the investigation, review one staff's files, review one client's files, and conducted a safety inspection. Additionally, LPA Almaraz conducted four staff interviews, eleven clients (C1, C2, C3, C4, C5, C6, C7, C C9, C10, and C11) interviews as listed on confidential names list (LIC 811) date June 21, 2023. LPA also interviewed a probation officer (PO). On February 21, 2023, the Department received a complaint that staff requested sexual favors from minors in care, staff offered vape pens to minors in care and due to lack of supervision, minors engaged in a sexual activity while in care. It was specifically alleged that staff #1 (S1) would offer C1 vape pens in exchange for allowing S1 to touch C1's private areas, S1 provided vape pens to clients, and...(continued on page 2...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Michael Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: TRINITY - YUCAIPAFACILITY NUMBER: VISIT DATE: 06/21/2023

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