facility_name: LIFT UP YOUR HEAD THERAPEUTIC HOMES, INC.

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

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

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

met_with: Yoldanda Johnson, Administrator


state: CA

summary: Facility Evaluation

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

report_type: Facility Evaluation

visit_type: Case Management

met_with: Yolanda Johnson


summary: Facility Evaluation

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

visit_type: Annual

met_with: Reverend Johnson Administrator


summary: Facility Evaluation

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

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


summary: Facility Evaluation - 1 deficiency

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

Deficiencies:
80019(e): Criminal Record Clearance

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

met_with: Rev Johnson, Administrator


summary: Facility Evaluation

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

met_with: Yolanda Johnson Executive Director


summary: Facility Evaluation

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

met_with: Yolanda Johnson Executive Director, Reverend Johson Administrator


summary: Facility Evaluation

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

met_with: Rev Randolph E Johnson, Administrator


facility_name: LIGHTHOUSE MENTORING CENTER 2

summary: Complaint Investigation - Unsubstantiated

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

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

report_type: Complaint Investigation

met_with: Administrator Nina Davis

complaint_status: unsubstantiated


summary: Complaint Investigation - Substantiated - 1 deficiency

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

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

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

complaint_status: SUBSTANTIATED

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


summary: Complaint Investigation - Substantiated - 1 allegation

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

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

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


summary: Complaint Investigation - Unsubstantiated - 1 allegation

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

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

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


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

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

met_with: Geramani Martin


raw_content:
Investigation Findings:
13On 6/27/23, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility to open a complaint investigation of the above allegation. LPA met with Administrator Nina Davis and informed of the purpose of the visit. LPA conducted confidential interviews and obtained relevent documentation and contact information. Based on confidential interviews and record review, the preponderance of evidence standard has been met, and therefore the above allegation is found to be substantiated. LPA is issuing a citation of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) section 87065. Personnel Duties. See LIC 9099-D attached. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Nina Davis, whose signature on this form confirms receipt. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Mariah Hawkins LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CENTRAL COAST SC/RES, TRAEGER AVE., SUITE FACILITY NAME: LIGHTHOUSE MENTORING CENTER 2FACILITY NUMBER: 075650005

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

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


summary: Complaint Investigation - Substantiated

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

Investigation Findings:
13On 7/24/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted an initial visit to the facility regarding an investigation into the complaint allegations listed above. LPA met with Administrator Nina Davis and informed of the purpose of the visit. Based on confidential interview, record review, and observation, the preponderance of evidence standard has been met, and therefore the above allegations are found to be substantiated. It was found that a plan was made with a 13-year-old resident's authorized representative to transport the resident to the airport and meet with the authorized representative, who would be accompanying the resident on the flight. Staff provided transportation to the airport but not to the authorized representative as agreed and therefore did not follow the transportation plan. Staff left the resident unattended at the wrong terminal without a phone, ID, or plane ticket and did not meet with the authorized representative nor inform them of arrival to the airport. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Mariah Hawkins LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CENTRAL COAST SC/RES, TRAEGER AVE., SUITE FACILITY NAME: LIGHTHOUSE MENTORING CENTER 2FACILITY NUMBER: VISIT DATE: 07/25/2023


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

Investigation Findings:
13On 3/7/25, Licensing Program Analysts (LPAs) Celeste Aparicio and Cole Oliver made an unannounced inspection to the facility for the purpose of delivering findings from a complaint investigation. LPA met with Galone Parker,Facility Manager and informed Facility Manager on the purpose of this visit. LPA reviewed documentation and conducted confidential interviews. Through the investigation it was found that on 12/30/24 a resident in care had been awake in the middle of the night displaying disruptive behaviors. During this incident the youth had been moving from the inside of the facility to the outside front yard. The complaint alleged that as staff attempted to redirect the youth, staff handled youth in a rough manner and staff did not treat youth with dignity. (See LIC9099-C). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Celeste Aparicio LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE FACILITY NAME: LIGHTHOUSE MENTORING CENTER 2FACILITY NUMBER: VISIT DATE: 03/07/2025

met_with: Facility Manager, Galone Parker


facility_name: LIGHTHOUSE MENTORING CENTER 3

raw_content:
Narrative:
... stated they drove into the youth to get the youth to move but later denied this in interview with LPA. Based on LPA's review of video footage, R1 placed self on the hood and windshield of the vehicle and was directed by staff to get off of the vehicle. The vehicle appears to be stopped at this time. R1 removes self from the vehicle, and as R1 steps off and away from the vehicle, the vehicle is propelled forward about a foot at approximately 5- MPH. The speed is low but is high enough to indicate the gas was pressed rather than just the brake being lifted. R1's body is very close to the vehicle, and R1's hand is either still on the vehicle or had just been removed. From the driver's side, from where the video is shot, it is not clear that R1 would not be hit by the vehicle. However, R1 does not show signs of being hit. The vehicle's horn is then honked 6 times in succession. There is no apparent purpose for the honking other than perhaps to warn R1 from walking in front of the vehicle as it is now moving. Based on this footage, LPA determines that the staff operating the vehicle did not act appropriately, and their actions put the health and safety of R1 at risk. Individuals should not jump onto vehicles, and individuals should demonstrate extra caution when operating vehicles around others, especially if others are making attempts to place themselves on top of the vehicle. Additionally, during this incident, staff S1 confirmed to police that S1 stated to youth R2 when R2 pulled out a knife, "You're bringing a knife to a gun fight," though S1 later denied this in interview with LPA. Police found an illegally concealed firearm during a search of S1's vehicle. S1 stated to police that S1 did not know at the time that S1's coworker (S2) had put S2's gun in S1's vehicle after extensive damage was caused to S2's vehicle earlier that day. S1 denied brandishing the weapon. Based on involved resident interview, S1 made a statement about not we're fighting but we're shooting. Based on record review and confidential interviews, S1 made a statement to R2 of a threatening nature that was a highly inappropriate thing to say to a child in care at a STRTP facility, as the statement could reasonably be interpreted by the youth as a threat. Multiple charges were filed against S1 by police, including assault with a deadly weapon, criminal threats, and cruelty to a child. The charges were ultimately dropped, but there is no evidence in supplemental reports that contradicts the findings mentioned above. The preponderance of evidence standard has been met, and therefore the above allegations are found to be Substantiated. LPA is issuing a citation per California Code of Regulations, Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section Personal Rights. An exit interview was conducted, and appeal rights and a copy of this report were provided to Asst. Director La Tanya Harper, whose signature on this form confirms receipt. ... stated they drove into the youth to get the youth to move but later denied this. Based on LPA's review of video footage, R1 placed self on the hood and windshield of the vehicle and was directed by staff to get off of the vehicle. The vehicle appears to be stopped at this time. R1 removes self from the vehicle, and as R1 steps off and away from the vehicle, the vehicle is propelled forward about a foot at approximately 5- MPH. The speed is low but is high enough to indicate the gas was pressed rather than just the brake being lifted. R1's body is very close to the vehicle, and R1's hand is either still on the vehicle or had just been removed. From the driver's side, from where the video is shot, it is not clear that R1 would not be hit by the vehicle. However, R1 does not show signs of being hit. The vehicle's horn is then honked 6 times in succession. There is no apparent purpose for the honking other than perhaps to warn R1 from walking in front of the vehicle as it is now moving. Based on this footage, LPA determines that the staff operating the vehicle did not act appropriately, and their actions put the health and safety of R1 at risk. Individuals should not jump onto vehicles, and individuals should demonstrate extra caution when operating vehicles around others, especially if others are making attempts to place themselves on top of the vehicle. However, based on record review and confidential interviews, it is not clear that any of the injuries R1 sustained were caused by staff's actions rather than by R1's own actions. Although the allegation may have happened or is valid, based on LPA's observations and interviews with residents and staff, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. Therefore, the allegation is Unsubstantiated. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Asst. Director La Tanya Harper, whose signature on this form confirms receipt.

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

met_with: Asst. Director La Tanya Harper


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Based on record review and confidential interviews, S1 made a statement to R1 of a threatening nature that was a highly inappropriate thing to say to a child in care at a STRTP facility, as the statement could reasonably be interpreted by the youth as a threat. Police found the illegally concealed firearm (belonging to S2) during a search of the vehicle. Multiple charges were filed against S1 by police, including assault with a deadly weapon, criminal threats, and cruelty to a child. The charges were ultimately dropped, but there is no evidence in supplemental reports that contradicts the findings mentioned above. The preponderance of evidence standard has been met, and therefore the above allegation is found to be Substantiated. LPA is issuing a citation per California Code of Regulations, Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section Personal Rights. An exit interview was conducted, and appeal rights and a copy of this report were provided to Interim Administrator Nina Davis.

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


raw_content:
Narrative:
Staff did not call the police immediately for each time the resident left due to the resident following a pattern of returning within 15 to 60 minutes. Additionally, the resident was a known risk for unauthorized leaves, which the facility expressed concerns with to the resident's authorized representative, but the facility found 1:1 supervision inaffective for the resident due to the resident becoming agitated by increased staff monitoring and being near staff, resulting in 1:1 supervision being terminated for the resident. The preponderance of evidence standard has been met, and therefore the above allegation is found to be substantiated. Due to the known risk for unauthorized leaves and not reporting the leave(s) immediately to the police, per facility protocol, LPA is issuing a citation of California Code of Regulations, Title 22, Section Plan of Operation. See attached LIC 9099-D. LPA also advises that per Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87065.5, the facility shall increase the number of direct care staff when a resident requires special care and supervision due to behavior. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Assistant Administrator La Tanya Harper, whose signature on this form confirms receipt. Additionally, the resident was a known risk for unauthorized leaves, which the facility expressed concerns with to the resident's authorized representative, but the facility found 1:1 supervision ineffective for the resident due to the resident becoming agitated by increased staff monitoring and being near staff, resulting in 1:1 supervision being terminated for the youth. There is not sufficient information to determine if a violation led to the incident occurring. Additionally, based on confidential interviews and record review, drug use is not allowed in the facility, and it has either not been witnessed by some parties or staff have been observed to confiscate contraband when they become aware of it. The facility is reported to have a menu residents enjoy, staff make quality meals and accommodate residents' dietary needs and preferences, residents are able to make their own meals if they prefer, and the facility was observed to have a large store of healthy food. However, at multiple visits, LPA observed food out of date or expired, including significantly moldy fruit that was exposed and accessible to residents. There is not sufficient information to prove that food service is overall inadequate. Further, based on confidential interviews, most residents report that staff do not bully and are not aggressive with residents. Staff use verbal intervention during altercations, but do not use physical intervention and are hands-off. Lastly, it was reported that medical documentation for a resident could not be located in order to provide to a paramedic who responded to the facility. The specific documentation could not be clarified, and LPA was able to have access to medical documentation. However, LPA advises that the facility ensure medical documentation is accessible to care staff in case of an emergency so that medical information can be provided to authorized parties. Although the allegation(s) may have happened or is/are valid, based on LPA's observations and interviews, there is not a preponderance of the evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegation(s) is/are unsubstantiated. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Assistant Administrator La Tanya Harper, whose signature on this form confirms receipt.

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

met_with: Assistant Administrator La Tanya Harper


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

raw_content:
Narrative:
...school schedule. Per the facility's program statement, "Transportation is provided to all youth/NMDs to school unless the youth/NMD prefers to walk to school in which in that case it is right for their age, developmental level, maturity and it's in their Needs and Service Treatment Plan," which was not followed. Further, Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section Transportation provides that facilities shall ensure transportation is provided to residents with any special arrangements agreed upon with the care team and documented in the needs and services. Based on confidential interviews and record review, staff perform room searches with two staff and the resident(s) present during the search. This policy/procedure is not listed in the facility program statement. Additionally, based on confidential interviews, multiple reports indicated that staff have made inappropriate comments and spoken inappropriately of or with residents, including referring to resident as nasty for making a mess and discussing a resident and their personal matters around or with other residents. One of these staff is no longer employed by the licensee. Based on confidential interviews, staff did open a resident's expected mailed ID in order to make a copy of it and has done this before. However, it is not a policy or a trend that staff will open residents' mail, and no mail is withheld from residents. Staff do request that residents open packages in front of staff in order to log it on residents' inventory list and to ensure the item is not dangerous or contraband. Resident reports indicate this has not been an issue for residents. However, this is not listed in the facility program statement, and residents have a right to confidentiality in the mail they receive. Lastly, based on confidential interviews, a resident requested to be taken to the emergency room for pain, but staff did not agree to transport resident. Resident and a peer called 911, and when the ambulance arrived, staff spoke to the medics, who then left. Later that night, the resident again expressed their concern of their pain, and staff called the advice nurse, who advised the resident be taken to the emergency room, and the resident was transported by ambulance due to the late hour. The preponderance of evidence standard has been met, and therefore the above allegations are found to be substantiated. LPA is issuing citations of California Code of Regulations, Title 22, Sections Plan of Operation and Health Related Services and STRTP ILS Sections Transportation and Personal Rights. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Assistant Administrator La Tanya Harper, whose signature on this form confirms receipt. Based on confidential interviews, staff do provide transportation to the hospital, but if an incident occurs in the middle of the night, when the ratio only requires one staff on shift and on-call staff cannot arrive quickly enough, staff will allow a resident to be transported by ambulance. LPA advises that per Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87065. Direct Care Staff/Child Ratios, facilities with a capacity of 6 or fewer residents, when one or more residents are present, shall have at least one direct care staff on call and capable of arriving to the facility within 30 minutes. Based on confidential interviews and record review, a resident had a medical visit on 11/14/21, and the visit summary advised a follow-up appointment be made for one (1) week later, which would be around 11/21/21. Medical records reflect that multiple visits were made, but no visit summary for a visit around this time was observed. Based on interviews and record review, some appointments were cancelled or could not be scheduled within the physician's requested time frame, and some health appointments the resident elected to not go to. Resident records do not reflect a trend of not scheduling doctor appointments. There is insufficient information to determine that appointments are not made for residents. Although the allegation(s) may have happened or is/are valid, based on LPA's observations and interviews, there is not a preponderance of the evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegation(s) is/are unsubstantiated. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Assistant Director La Tanya Harper, whose signature on this form confirms receipt.

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

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

Deficiencies:
87074: (3) Extracurricular, personal enrichment,...and social activities

met_with: Assistant Director La Tanya Harper

title: Transportation c) Unless other arrangements are specified in the Needs and Services Plan or the Transitional Independent Living Plan...a licensee shall ensure transportation is provided to...


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

met_with: Facility Manager Geramani Martin


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


raw_content:
Investigation Findings:
13On 08/06/ Licensing Program Analyst (LPA), Celeste Aparicio made an unannounced inspection to the facility for the purpose of delivering findings from a complaint investigation. LPA met with Facility Manager and informed on the purpose of this visit. LPA reviewed documentation and conducted confidential interviews. After the review of documentation and interviews with relevant parties, it was found that the allegations could not be corroborated due to inconsistent statements and documentation obtained. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided to facility, whose signature on this form confirms receipt UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Celeste Aparicio LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


raw_content:
Investigation Findings:
13On 3/7/25, Licensing Program Analysts (LPAs) Celeste Aparicio and Cole Oliver made an unannounced inspection to the facility for the purpose of delivering findings from a complaint investigation. LPA met with Geramani Martin, Administrator and informed Administrator on the purpose of this visit. LPA reviewed documentation and conducted confidential interviews. Through the investigation it was found that on 1/3/25, R1 and S2 got into a verbal argument regarding R2's confidential information. (See LIC811). The complaint alleged that during this verbal argument, staff did not treat youth with dignity. After the review of documentation and interviews with relevant parties, it was found that the allegation could not be corroborated due to insufficient evidence. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted, appeal rights were provided, and a copy of this report was left with Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Celeste Aparicio LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Administrator,Geramani Martin


facility_name: LIGHTHOUSE MENTORING CENTER 4

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

raw_content:
Narrative:
The needs and services plan dated 10/21/21 includes the following: "Transition Plan: [R1]'s current plan is to graduate high school and move back with her grandmother or transition to a county connected independent living program. The staff and counselors at Lighthouse Mentoring Center are supporting [R1]'s connection with her grandmother and guiding and educating her on the resources available through the Independent Living Program. Additionally, [R1] is working on developing other independent living skills, such as securing, and retaining employment, budgeting and managing her own transportation." The complaint report was filed on 10/20/21 in response to an incident that day. The transition plan was updated after the incident. Administrator informed LPA that the plan was not updated before because the plan to manage own transportation had been verbally discussed and agreed upon at a CFT. This was, though, before R1 changed schools. Additionally, the facility did not have a record of bus routes that R1 was to utilize to make their way home, and Administrator was unaware of what bus route R1 would need to take to get home to the facility, which is a safety concern. Based on LPA's review of local bus routes, the 9-minute car ride home would have taken R1 an average of 2 hours to get home by bus. The only route that would be quicker (but still 90 minutes) costs more than the amount of money R1 is provided to self-transport. Multiple routes require multiple transfers, and R1 is a known AWOL risk, per interview and record review. Staff are able to transport youth to work after school on days R1 works, but the facility does not have a schedule for R1's job, because the employer does not provide these to R1. However, staff availability indicates that staff are available to pick up the youth after school. Further, the route home from R1's previous school was about 37 to 44 minutes by bus. The preponderance of evidence standard has been met, and therefore the above allegation is found to be Substantiated. There is one citation. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Tracy McWoodson, whose signature on this form confirms receipt.

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

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

Deficiencies:
87074: ...(2) School... (3)	Extracurricular, enrichment...

met_with: Administrator Tracy McWoodson

title: Transportation  (c) Unless other arrangements are specified in the Needs and Services Plan or the Transitional Independent Living Plan..., a licensee shall ensure transportation is provided to the following


raw_content:
Narrative:
Residents upstairs call for staff, both of whom are downstairs. S1, who was upstairs with the residents, had gone downstairs prior to the incident to use the restroom. S1 reported that S2 was made aware of this and was nearby downstairs with another resident but may not have been able to see the residents upstairs. S2 reported that S2 was not made aware that S1 was using the restroom and that S2 was in the kitchen area with the fifth resident in care. S2 responded when called by the residents. The lighter, and per staff statements, multiple lighters on multiple occasions, were confiscated from R3. However, due to lack of supervision, the lighter could not be confiscated at the time of the incident, the incident of R3 using a dangerous item could not be prevented or intervened, and R3's injury could not be prevented. Further, resident and staff statements indicate that staff interactions with youth are not always trauma-informed and that multiple staff members at times use an inappropriate and disrespectful tone with residents when delivering information or explaining consequences. When staff share information with residents, the tone, word choice, and body language are important in delivery of that information. Additionally, if a resident responds negatively to a staff statement, staff are responsible for ensuring they use trauma-informed care, per policy procedures, to calm the resident, communicate their intentions, and to maintain the relationship between staff and residents and the health and safety of the resident. Staff tone and attitude contribute significantly to the environment in the facility. The preponderance of evidence standard has been met, and therefore the above allegation(s) is/are found to be Substantiated. LPA is issuing a citation of California Code of Regulations, Title 22, Division 6, Chapter 1, Article 7, Section 80087(g) Buildings and Grounds and Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87065.2(b)(1) Personnel Duties and Section 87072(c) Personal Rights. An exit interview was conducted, appeal rights provided, and a copy of this report left with Administrator Tracy McWoodson, whose signature on this form confirms receipt.

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

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

Deficiencies:
87065.2: (1) Supervision, protection, and care of children at all times, individually and in groups.

met_with: Administrator Tracy McWoodson, Clinical Director Phyllis Ritter

title:
Personnel Duties
(b) Direct care staff shall perform the following duties


raw_content:
Narrative:
S1 did not engage with R1 as part of planned ignoring and did not realize that P1 was overhearing R1's statements. By staff taking a personal call while at the facility, confidential information and/or identifying information such as names, voices, and private conversations of residents can be heard by individuals not affiliated with the facility or youths' care teams, which is a privacy and personal rights risk. Immediately prior to the incident, S1 had gone to use to the downstairs bathroom, and S2 was downstairs, and staff were not able to prevent P1 from entering the facility and going upstairs. The front door, which is typically locked, per staff, was unlocked. P1 went upstairs trying to identify who it was who was disrespectful to S1 earlier. R1 was in another resident's room, which is the door nearest the top of the stairs. P1 entered, and the altercation began. The preponderance of evidence standard has been met, and therefore the above allegation(s) is/are found to be Substantiated. LPA is issuing a citation of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87065.2(a)(2) Personnel Duties and Section 87072(c)(10) Personal Rights. An exit interview was conducted, appeal rights provided, and a copy of this report left with Administrator Tracy McWoodson, whose signature on this form confirms receipt.

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

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

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

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


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

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


raw_content:
Narrative:
Additionally, based on record review, a resident was alleged to have been denied medication, but records reflect prescribed medications were administered and logged. Based on confidential interviews, the allegation may have no reasonable basis. However, during record review, LPA observed that some medications were not administered for a few days due to needing to be filled, and one medication was potentially administered incorrectly or logged incorrectly. A medication, Aripiprazole, was prescribed at 1 1/2 tablets at bedtime for 15 days and filled on 2/18/22 with 1 refill, administered for 15 days, and then filled on 3/18/22 with 0 refills. The facility continued administering daily until they ran out after 4/10/22. If the medication was only to be administered for 15 days, administration should have stopped after 4/1/22, and at 1 1/2 (1+1/2) dosage, the facility would be out of the medication after 4/1/22. However, after filling the 3/18/22 prescription, the records reflect that staff notated the medication was not administered due to needing to be filled. The resident is no longer in care, so a medication count cannot be conducted. Although the allegation(s) may have happened or is/are valid, based on LPA's observations and interviews, there is not a preponderance of the evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegation(s) is/are unsubstantiated. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Tracy McWoodson, whose signature confirms receipt.

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

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


raw_content:
Narrative:
allegations, one confirmed, and two were unable to determine. Based on record review, clients were threatened by other minors. The facility staff coordinated with other facility staff and the attending school to mitigate physical violence. LPA was not able to interview the client involved because they were on an extended unauthorized absence from the facility, then declined to interview. The client is now reunified with a relative. Although the allegations that facility does not provide a safe environment for minor, facility staff are verbally abusive to minor, and other minors fight and threaten minor may have happened or is/are valid, based on LPA's observations and interviews, there is not a preponderance of the evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegations are unsubstantiated. LPA conducted an exit interview with Danielle Rosenbaum, Facility Manager, whose signature confirms the receipt of this document.

Investigation Findings:
13On 10/24/2022 at 11:20AM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the facility. The purpose of this visit is to inform the facility of the findings on the listed allegations. LPA met with Danielle Rosenbaum, Facility Manager. During the course of the investigation, LPA Hood conducted six confidential interviews. LPA reviewed the client Needs and Services Plan, incident reports, and an Investigations Branch (IB) investigation done into different allegations regarding the same youth. LPA reviewed the CWS investigation regarding this incident, CPS did not conduct an investigation because it did not meet child endangerment criteria. Based on record review and interviews, the facility provided a safe environment for minor and followed facility protocol when dealing with external threats. Based on interviews, there is conflicting information whether staff are verbally abusive to minors in care. Of the six interviews, three interviewees denied these UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Selena Hood LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: LIGHTHOUSE MENTORING CENTER 4FACILITY NUMBER: VISIT DATE: 10/24/2022

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

met_with: Danielle Rosenbaum


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
The resident previously self-transported via public transportation with staff transporting to the local BART station. However, following an incident that caused a safety concern for the resident, the care team agreed to have staff transport the resident. The facility and care team have developed and implemented a plan to gradually transition the resident back to self-transport via BART. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Tracy McWoodson, whose signature on this form confirms receipt.

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


summary: Complaint Investigation - Unsubstantiated - 1 deficiency

raw_content:
Narrative:
During another incident, one resident was downstairs in the front living room on a phone call monitored by the staff on duty. Another resident was upstairs, unsupervised. The front living room is visible from the upstairs landing and hallway, but the main kitchen/dining/family room area is not visible from the front living room. The resident upstairs came downstairs, entered the main kitchen/dining/family room, and exited the facility through the back sliding door. This resident then returned about 5 minutes later with contraband not visible to staff, and returned upstairs. The investigation found that the call the resident was on was not a required supervised call but that staff observe the resident on the phone to ensure the resident does not make unapproved calls afterward, as the resident does have a list of calls that need to be approved and/or supervised. Later, both residents were in one of their bedrooms and shared the contraband, which was learned to be a can of alcohol and a nicotine vaporizer pen obtained by the resident who exited the facility from an adult not affiliated with the facility. Additionally, multiple reports obtained described supervision at the facility as relaxed or that staff are disengaged or distracted on their phones. The incident report submitted for this incident also did not reflect that engagement or redirection was done. Lastly, the staff could have been stationed upstairs and had sight of the resident on the phone or could have engaged with the resident who exited the facility and continued listening for a break in the phone discussion or for redialing, or the facility could have increased staffing to meet the extra supervision needs of the resident with required monitored phone use. Regarding the third allegation above, the reports obtained indicate that due to a lack of supervision allowing residents to enter other residents' rooms, multiple residents have had their personal belongings stolen by other residents, and sometimes those items have been destroyed, including clothing, a journal, and a family photo. The preponderance of evidence standard has been met, and therefore the above allegations are found to be substantiated. LPA is issuing citations of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), section Plan of Operation and 87065. Personnel Duties. See attached LIC 9099-D. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Tracy McWoodson, whose signature on this form confirms receipt.

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

Deficiencies:
87065.2: (1) Supervision, protection, and care of children at all times, individually and in groups.

title:
Personnel Duties
(b)(1) Direct care staff shall perform the following duties


facility_name: LIGHTHOUSE MENTORING CENTER 5

summary: Facility Evaluation

raw_content:
Narrative:
On 7/10/25 at 11am, Licensing Program Analyst (LPA) Celeste Aparicio met with Executive Director Assistant, La Tanya Harper and Executive Director, Jay Lightner for the scheduled Component II face-to-face meeting. The meeting was held over Microsoft Teams. The purpose of this meeting was to discuss the facility's Plan of Operation and Program Statement. The following items were discussed: - Goal/Purpose of the STRTP - Basic Services and Planned Activities - Needs and Services Plans - Care and Supervision Policies - Staff Training - Emergency Intervention Policies - Reporting Requirements - Visitation Policies - Background Clearance/Guardian Process LPA provided clarification on the next steps in the application process. LPA scheduled Component III for Monday August 4 at 10am. An exit interview was conducted, and a copy of this report was provided to Executive Director Assistant, La Tanya Harper via email.


summary: Facility Evaluation

raw_content:
Narrative:
On August 4, 2025 at 10am, Licensing Program Analyst (LPA) Celeste Aparicio conducted a virtual Teams Meeting with Lighthouse Mentoring Center to conduct Component III. The following were the attendees of the meeting: Celeste Aparicio, Licensing Program Analyst; La Tanya Harper, Executive Director Assistant; and Jay Lightener, Executive Director. During the meeting the presentation for Component III was presented. A copy of the presentation was emailed to the Lighthouse Mentoring Center. LPA provided clarification on the next steps for the Pre- Licensing inspection. LPA discussed with the licensee that the Pre-licensing will be conducted once the Systems of Care (SOC) branch finishes the second review of the program statement. An exit interview was conducted, and a copy of this report was provided to Executive Director Assistant, La Tanya Harper via email.

met_with: Executive Director Assistant, La Tanya Harper and Executive Director, Jay Lightner


summary: Facility Evaluation

raw_content:
Narrative:
On August 20, Licensing Program Analyst (LPA) Celeste Aparicio met with Executive Director Assistant, La Tanya Harper and Executive Director, Jay Lightner, for a prelicensing inspection. Using the CARE Inspection Tool, LPA toured the facility site and grounds and discussed the facility's application. 1. Facility grounds inspected. Grounds are clean and free from observable hazard. Clear passageways throughout the facility. The facility does not have a swimming pool or any bodies of water. Firearms are not allowed on facility premises. 2. Adequate indoor activity space and materials observed, and outdoor activity space was observed. 3. Procedures for locked and centrally stored medications observed. 4.Adequate storage space observed. 5. Individual beds in good repair observed. 6. The house is two story and has 4 client bedrooms. Bedrooms are accommodating of all required furnishings. 7. Adequate food storage space observed. Facility will add appropriate supply of required foods and emergency foods upon placement of youth in the home. 8. Sample menu posted. 9. All appropriate forms posted within client view. 10. Dining room equipped with large table and chairs accommodating of all clients. 11. Facility has 3 restrooms for client use, all are operable. 12. Client files will be kept in a locked filing cabinet, locked in the staff office. 13. Staff files will be kept locked at the facility main office, and will be available for review at facility, within a reasonable time frame of request by LPA. Applicant is associated through Guardian and has been fingerprint cleared. Prior to accepting placement's, all staff must be fingerprint cleared and associated to the facility. Discussed Guardian process with the facility. Based on this inspection, the facility will be ready for licensure. A copy of this report was provided to Executive Director Assistant, La Tanya Harper.

visit_type: Prelicensing


summary: Facility Evaluation

raw_content:
Narrative:
On 12/03/2025, Licensing Program Analyst (LPA) Celeste Aparicio conducted a post-licensing inspection. LPA met with Administrator Jasmine Jackson and explained the purpose of the visit. At the beginning of the inspection, two staff members were present, and no clients were in the facility as the clients were at school. At 3:22 p.m., two clients returned from school. LPA utilized the CARE Inspection Tool to complete the inspection. A tour of the facility was conducted, and facility records were reviewed. LPA also obtained the residents' school information and reviewed board meeting minutes. The facility was observed to be clean, well-maintained, and in safe condition. The kitchen and bathrooms were sanitary; resident bedrooms were appropriately furnished, provided clean linens, and offered adequate storage space. Potentially dangerous items-including chemicals, knives, and medications-were stored securely and were inaccessible to clients. A review of staff and client files found them to be complete and in compliance. LPA identified three areas where technical assistance may be beneficial. Please refer to the attached LIC Advisory Note for guidance related to Sections 87075(b), 87077(a)(3), and 87089.1(e). LPA conducted one staff interview and one client interview. LPA was unable to interview the second client, as the client was asleep. No deficiencies were observed or cited during today's visit. An exit interview was completed, and a copy of this report was provided to the Administrator.

met_with: Administrator, Jasmine Jackson


facility_name: LIGHTHOUSE MENTORING CENTER, THE

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

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

met_with: Administrator Maurice Jones


met_with: Assistant Clinical Director Jason Braden


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Investigation Findings:
13On 12/28/22 and 11: AM, Licensing Program Analyst (LPA) Alyssa Ng conducted a complaint inspection at The Lighthouse Mentoring Center located at Garden Court, Antioch, CA 94509 and spoke with Maurice Jones, Administrator. The purpose of the inspection was to deliver the findings for the above complaint allegations. During investigation, interviews were conducted, and incident reports were reviewed, and it was determined that facility did not meet reporting requirements, minors engaged in a physical altercation, minor sustained injury while in care, and insufficient staffing. Based on LPA's interview with staff, client, and record review(s), the preponderance of evidence standard has been met, therefore the above allegations, Facility did not meet reporting requirements, Minors engaged in a physical altercation, Minor sustained injury while in care, and insufficient staffing is found to be SUBSTANTIATED. Facility is being cited for violation of California Code of Regulations (CCR), Title 22, Division 6 & Chapter 1: 80061(b)(1)(D) Reporting Requirements, 80078(a) Responsibility for Providing Care and Supervision, and 80072(a)(3) Personal Rights. Please refer to attached 9099D. At this time, three deficiencies were given. An exit interview was conducted, appeal rights provided and discussed, and a copy of this report was sent to Maurice Jones, Administrator . SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Alyssa Ng LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, TRAEGER AVE., SUITE FACILITY NAME: LIGHTHOUSE MENTORING CENTER, THEFACILITY NUMBER: 075600414

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

met_with: Maurice Jones


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


met_with: Eugene Denard


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

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


met_with: Facility Manager, Eugene Denard

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


facility_name: LLU JOSHUA PLACE

summary: Facility Evaluation

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Narrative:
On February 5, 2025, at 2:00 pm, Licensing Program Analyst (LPA) Charmaine Linley, met with applicant Ashley Martinez for Component II Orientation via Microsoft Teams Meetings. LPA went over revisions needed for the application prior to licensure. LPA sent a copy of the LIC 184, Notice of Incomplete Application, and additional correspondence to assist with the revisions needed to the application via email. A copy of this report was provided to the applicant along with the signed Orientation form indicating Component II has been completed via email. A copy of this report will be placed in the facility file.

met_with: Ashley Martinez


summary: Facility Evaluation

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Narrative:
On April 23, 2025, Community Care Licensing (CCL) conducted an office conference with the Short-Term Residential Treatment Program (STRTP) applicant Ashley Martinez regarding their application denials for LLU Joshua Place (366000017) and LLU Joshua Place 2 (366000035). Present at the meeting was: LaCresha Cook, Regional Manager (RM), Ashley Martinez, Executive Director (ED), Ann Valenzuela, Licensing Program Manager (LPM), Charmaine Linley, Licensing Program Analyst (LPA) and Kimberly Abdul-Malik, Treasurer/Board Member, was present via cell phone. The meeting was called to address concerns regarding the applicants submission of an incomplete application and history of noncompliance. RM explained that CCL is denying the applicant's STRTP applications for both LLU Joshua Place (366000017) and LLU Joshua Place 2 (366000035). RM further explained that as of April 23, 2025, the STRTP applications would be officially denied. The denial of the application is based upon failure to provide satisfactory evidence that the applicant can meet or conform to the licensing requirements in Health and Safety Code Chapter 3, commencing with Section 1500; Title California Code of Regulations, Division 6, Chapter 1, commencing with Section 80000; and the CDSS Short-Term Therapeutic Program Interim Licensing Standards ("ILS"). This decision is based on the evidence set forth in the reports, statements, and other documentary evidence contained in the official files compiled by the department. The applicant disagrees with the information shared in the meeting and states that 90% of the information is included in the pending revisions. Applicant states she feels she is being unfairly treated and plans to follow up this matter with the chain of command within the Community Care Licensing Division. *** RM informed that a denial notice will be sent to the applicant explaining all reasons for the application denial and provided in Health and Safety Code Section 1526, an applicant may appeal a denial by submitting a written appeal within 15 days after the licensing agency mails the denial notice. The appeal should include the facility name, facility number, facility address and a copy of the denial letter. The appeal must be post marked or delivered on or before 15 days from the date of the denial letter. RM explained that if this decision is not appealed on or before the due date the denial will be final. RM informed applicant that the appeal request is sent to the following address: Jean Chen, Program Administrator, Statewide Children's Residential Program Office, P Street, MS 9-14-880, Sacramento, CA 95814. A copy of this report was provided to Ashley Martinez. The signed report will be placed in the facility application file.


facility_name: LYON

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Narrative:
statements saying, "I love you" and referring to each other as "babe." Confidential interviews reported the expression of love was given to multiple residents to demonstrate care, compassion and to build rapport with residents, and the term "babe" was common language within the facility. Confidential interviews could not confirm or dispute that the messages sent between S1 and C1 were of a romantic nature or there was an inappropriate relationship between S1 and C1. Based on record review and confidential interviews the allegation of Staff (S1) was engaging in an inappropriate relationship with minor (Child #1 [C1]), may or may not have occurred, however it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of the report was provided along with appeal rights to Lyon Short Term Residential Therapeutic Program (STRTP) Administrator (ADM) Courtney Brandon.

Investigation Findings:
13On February 10, 2023 at 12:10 pm Licensing Program Analyst (LPA), Nicole Strickland, met with Lyon Short Term Residential Therapeutic Program (STRTP) Administrator (ADM), Courtney Brandon, to deliver the finding for the above stated allegation. LPA conducted an inspection of the facility on March 16, 2022 at approximately 1:30 pm and no immediate deficiencies were observed. The investigation was conducted LPA Strickland and included interviews with ADM, Staff #1 (S1). Three confidential witness did not respond to LPA's request for an interview or current whereabouts were unknown and therefore were not interviewed. In addition, county records and facility records were reviewed. On March 10, Community Care Licensing (CCL) received an allegation alleging Staff (S1) was engaging in an inappropriate relationship with minor (Child #1 [C1]). Specifically it was reported during computer checks at the facility messages between S1 and Child #1 (C1) were found indicating a romantic relationship between the two. Confidential interviews and record review revealed messages between the two included UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Nicole Strickland 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: LYONFACILITY NUMBER: VISIT DATE: 02/10/2023

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

met_with: Courtney Brandon


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Narrative:
and encourage them to stay. If clients AWOL staff will contact the appropriate parties to report the AWOL. Further details stated that there are some clients that chronically AWOL from the facility. Other details gathered from confidential interviews state that staff does not prevent clients from AWOL and does not do much to prevent clients from leaving the facility. Regarding the allegation that staff yells at minor and staff does not treat minor with dignity and respect, confidential interviews disclosed that staff yells at minors. Other interviews provided information that staff will use a stern tone of voice in order to re-direct and de-escalate minors when clients become aggressive towards staff or other peers in the home. Further details gathered from confidential interviews, state that clients and staff will joke with one another and that sometimes staff or clients will go too far and clients' feelings will get hurt. Further information gathered, denied that staff yells at minors and that every client is treated with respect and did not witness or hear staff yelling at minors in care or not treating minors with dignity and respect. Regarding the allegation that staff confiscated minor's privilege of phone and television usage, confidential interviews disclosed that staff denies clients phone and television usage. Other confidential interviews stated that staff will take away privileges but that clients get the privileges back. Further details gathered disclosed that some clients misused their usage and therefore had privileges taken away but were later given them back. Based on record review and confidential interviews the allegations alleging that minor went AWOL from facility, staff yells at minor, staff does not treat minor with dignity and respect, and staff confiscated minor's privilege of phone and television usage, may or may not have occurred. However, it is not supported or proven by the evidence. Confidential interviews could not confirm or dispute these allegations; Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted, appeal rights were discussed and provided. A copy of this report was given to Administrator, Linda Poythress.

Investigation Findings:
13On June 21, 2023 at 11:02 am Licensing Program Analyst (LPA), Emina Preciado, met with Lyon STRTP Administrator (ADM), Linda Poythress, to deliver the findings for the above stated allegations. LPA Lisi Leon conducted an inspection of the facility on June 21, 2022 at approximately 12:15 pm and no immediate deficiencies were observed. The investigation included interviews with two staff, one facility manager (FM, S1, and S2) and three out of six foster youth (C1, C5, C6). Two confidential witnesses did not respond to LPA's request for an interview and one confidential witness whereabouts are unknown and were, therefore, were not interviewed. In addition, county records and facility records were reviewed. On June 15, 2022, Community Care Licensing (CCL) received four allegations alleging that minor went AWOL from facility, staff yells at minor, staff does not treat minor with dignity and respect, and staff confiscated minor's privilege of phone and television usage. Regarding the allegation that minor went AWOL from the facility, confidential interviews disclosed that staff encourages clients to not AWOL by using re-direction so that clients do not leave *next page...* UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Emina Preciado 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: LYONFACILITY NUMBER: VISIT DATE: 06/21/2023

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

met_with: Linda Poythress


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Narrative:
Confidential interviews reported that staff created a plan for C1 not to have phone privileges due to behavior issues and house rules, and C1's authorized representative agreed to the plan. Confidential interviews reported that C1 was using the phone for extended periods and using the phone outside of the house rules time. Confidential interviews reported that C1 would take the facility's house phone, hide it in their room, and keep it for personal use. Confidential interviews revealed staff created boundaries for C1's phone use due to C1's history of talking with unknown people and becoming physically upset whenever C1 would finish the phone call. Confidential interviews and documentation revealed that after C1 talked with unknown people, staff feared that C1 would become physical in interacting with staff. Confidential interviews revealed when C1 was on hold of the facility house phone, and if C2 and C3 requested to use the phone, staff would allow them to use the staff phone for their calls. Based on inconsistence confidential interviews, the allegations that staff are not allowing youths in care (C1, C2 & C3) to use the telephone is unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted, and a copy of this report LIC 9099 and the appeal rights were discussed and provided to Stacey Rougely, Administrator.

Investigation Findings:
13On April 4, 2024, Licensing Program Analyst's (LPA's) Cynthia Robinson and Leslie Covarrubias met with Stacey Rougely, Administrator to deliver the compliant findings to the allegation listed above. LPA Robinson conducted a health and safety inspection on 02/09/2024 at 9: AM, and no immediate health and safety concerns were observed. During the investigation, LPA Robinson conducted confidential interviews with Staff 1(S1), Staff 2 (S2), Staff 3 (S3), Staff 4 (S4), and Clients (C1, C2 & C3). LPA obtained copies of related Special Incident Reports (SIRs), the client roster and staff roster, and the placement agreements for C1, C2, and C3. LPA obtained other pertinent documents needed for the investigation. On 02/29/2024, Community Care Licensing (CCL) received a complaint that facility staff are not allowing youths (C1, C2, & C3) in care to use the telephone. It was reported to CCL that C1 was not allowed to use the phone for a week, and the client's phone was missing for a week, thus not allowing C1, C2 & C3 to use the phone. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Cynthia Robinson LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: LYONFACILITY NUMBER: VISIT DATE: 04/04/2024

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

met_with: Stacey Rougely, Administrator


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Narrative:
During the investigation, there was no corroborating evidence to support the above allegation. Although the Department received information that S1 pushed C3 out of the way to unplug the television. Confidential interviews revealed that S1 did not touch C3 but reached around C3 to unplug the television. Confidential interviews revealed that C3 asked C1 and C5 to be witnesses to say S1 had pushed C3, however, C1 and C5 retracted their statements and stated they never saw S1 push C3 out of the way. Based on inconsistent confidential interviews, the allegations that S1 handled minor in care in a rough manner may have occurred, however, is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with appeal rights was provided to Lyon Short Term Residential Therapeutic Program (STRTP), Youth Partner, Randy Davis.

Investigation Findings:
13On 05/15/24 at 09: AM, Licensing Program Analyst (LPA) Sarah Lo met with Youth Partner, Randy Davis, to deliver the finding for the above complaint allegation at Lyon Short Term Residential Therapeutic Program (STRTP). On 12/19/23, LPA Emina Preciado inspected the facility's physical plant, and no immediate health and safety hazards were observed. The investigation included interviews with two staff members (S1 and S2), Residential Manager (RM), Probation Officer (PO) and five clients (C1, C2, C3, C4 and C5). Clients' Needs and Services Plans and case notes were reviewed. On December 15, 2023, Community Care Licensing received an allegation that staff (S1) handled minor in care in a rough manner. Specifically, it was reported that S1 had used the hands to push C3 out of the way to unplug the television and S1 used their body to shove C3 away from the television to keep from C1 plugging in the television cord. (Continued on LIC 9099c) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Sarah Lo LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: LYONFACILITY NUMBER: VISIT DATE: 05/15/2024

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

met_with: Youth Partner, Randy Davis


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Narrative:
Other confidential interviews stated that they did not hear S1 say inappropriate statements to C1. In addition, confidential interviews disclosed that S1 did not close the door on C1's hand, but C1 slammed the mini-refrigerator door shut themselves (C1). Regarding the allegation that staff (S1) threatened a minor (C1) in care, confidential interviews disclosed that S1 threatened "to call their people" on C1 and threatened C1 with a firearm. Confidential interviews indicated that S1 did not use threatening words toward C1 or a firearm. Per the facility, no firearms are kept at the facility. LPA could not determine if S1 threatened C1 or not. Based on inconsistent confidential interviews, the allegation that staff slammed a door on a minor's hand and staff threatened a minor in care may have occurred, however is not supported, or proven by evidence. Therefore, the above allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report LIC 9099 and the appeal rights were discussed and provided to Stacy Rougely, Administrator.

Investigation Findings:
13On December 17, 2024, Licensing Program Analyst (LPA) Cynthia Robinson met with Stacy Rougely, Administrator to deliver the complaint findings to the above allegations. LPA Robinson inspected the STRTP on 09/13/2024 and observed no health and safety concerns. LPA Robinson obtained documents pertinent to the investigation. During the investigation, LPA Robinson conducted confidential interviews with Staff 1 (S1), Staff 2 (S2), Staff 3 (S3), Client 1 (C1), Client 2 (C2), and Client 3 (C3). LPA attempted to interview Client 3 (C3) and Client 4 (C4); however, C3 and C4 declined to be interviewed. On 09/09/2024, Community Care Licensing (CCL) received a complaint that staff (S1) slammed a door on a minor's (C1) hand, and staff (S1) threatened a minor (C1) in care. Specifically, it was alleged that S1 slammed C1's hand with a mini-refrigerator door. Confidential interviews disclosed that C1 attempted to reach the mini-refrigerator to grab a Gatorade drink, and S1 slammed the door on C1's hand. Additional confidential interviews disclosed that C2 heard the refrigerator close, and S1 allegedly told C1, "Your hand shouldn't have been there". (Continued on LIC 9099C...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Cynthia Robinson LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: LYONFACILITY NUMBER: VISIT DATE: 12/17/2024

met_with: Stacy Rougely, Administrator


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Narrative:
Documentation reported that the facility notified the authorized representatives the day the clients were evacuated to the hotels on 01/10/2025. LPA was unable to determine the timeframe of when the minors' authorized representatives were or weren't contacted. Based on inconsistent confidential interviews and documentation, the allegation that staff did not properly report an incident involving the minors is unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of evidence to prove that the alleged violations occurred. LPA issued a Technical Violation LIC9102, to remind the facility to follow the reporting requirements in the STRTP Interim Licensing Standards. An exit interview was conducted, and a copy of this report LIC 9099 and the appeal rights were discussed and provided to Stacy Rougely, Administrator.

Investigation Findings:
13On March 24, 2025, 2024 at 12: AM, Licensing Program Analyst (LPA) Cynthia Robinson conducted an unannounced visit to Olive Crest Lyon Short-Term Residential Therapeutic Program (STRTP) to deliver the investigative findings for the above allegation. On 01/17/2025, LPA Robinson conducted a health and safety inspection at the STRTP and obtained documents pertinent to the investigation. LPA interviewed clients (C1, C2, and C3), staff (S1 and S2), County Social Workers (CSW1 and CSW2), and Probation Officer (PO). On 01/15/2025, Community Care Licensing received an allegation that staff did not properly report an incident involving the minors. It was alleged that during a facility evacuation due to power outages, the clients were placed in a hotel for the weekend from 01/10/2025 to 01/13/2025 and authorized representatives of the clients (C1, C2, C3, C4, and C5) were not notified. Confidential interviews reported that the facility did not contact authorized representatives until clients were placed back in the facility but was unsure on which day authorized representatives were notified. (Continued on LIC 9099C...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Cynthia Robinson LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: LYONFACILITY NUMBER: VISIT DATE: 03/24/2025

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


summary: Facility Evaluation

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Narrative:
***This is an Amended Report of the report issued on 10/05/21. On October 5, 2021, at 11: AM Licensing Program Analyst (LPA) Leslie Covarrubias and Licensing Program Manager (LPM) Jennifer Smith arrived at Lyon, Short Term Residential Program (STRTP). LPA and LPM met with Residential Manager, Tyresha Calhoun. The purpose of the visit is to conduct an annual inspection of the facility. At 11: AM, Residential Manager, Tyresha Calhoun, led the physical inspection of the facility. The home is set up as follows: Bedroom #1- Was furnished with one twin bed. Sleeps one client. Bedroom #2- Was furnished with one twin bed. Sleeps one client. Bedroom #3- Was furnished with one twin bed. No client is placed in this room at this time. Bedroom #4- Was furnished with one twin bed. Sleeps one client. Bedroom #5- Was furnished with one twin bed. Sleeps one client. Bedroom #6- Was furnished with one twin bed. Sleeps one client. Bedrooms are arranged so that only one child is placed per room. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There is adequate drawer and closet space for children's belongings. The dresser drawer in room #2 was observed to be cracked approximately in the middle of drawer and on the verge of breaking off. A physical plant inspection was completed and included the facility's kitchen area, three refrigerators/freezers, food storage areas, client rooms, two bathroom/showers, and community gathering area and dining area. Facility grounds are clean and free of debris and observable hazards. Sports equipment/toys/books/games were observed for client's recreation time. There is adequate indoor and outdoor activity space. Facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and the menus were posted. At the time of inspection the facility license was observed to be posted in the staff office, which is not a public area of the facility. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsperson poster. Medications are locked and centrally stored inside staff office. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client's bathrooms was measured to be an appropriate temperature. Per the Residential Manager, no firearms or weapons are allowed in the facility. LPA and LPM inspected the facility vehicle, and observed that the second row seat belt buckles are missing the outside covers. The facility was advised not to allow use of the second row until repair of the seat belt buckles is completed. LPA and LPM also inspected the First Aid Kit and found it was missing tweezers and scissors. Licensee has Mental Health Program Approval that is valid through 12/2021. Licensee has obtained National Accreditation that is valid through 10/2021. Licensing fee payments have been paid and there is currently a balance of $0. No deficiencies were cited at this time. An exit interview was conducted and a copy of this report, LIC9102 and appeal rights were provided to Residential Manager, Tyresha Calhoun.

met_with: Residential Manager, Tyresha Calhoun


summary: Facility Evaluation

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Narrative:
On November 10, 2021, at 8:35am, Licensing Program Analyst (LPAs) Ronnesha Fountain and Leslie Corvurriabias conducted an announced inspection. The purpose of the inspection was to complete the continuation inspection for STRTP annual inspection that was initiated on October 05, 2021. LPA's already completed the physical inspection, staff records, and staff interviews of the facility. During this annual inspection continuation LPAs interviewed four of the six clients to ensure the STRTP are meeting the Title Regulations and Interim Licensing Standards (ILS), see LIC 811 dated 11/10/21. The client interviews are located under the LIC 809 dated 10/22/21. Based on interview with clients, there was some confusion over the "point system" used that determines the amount of cash a client can keep on them physically, but the amount that is deposited into their savings does not change. In-addition, there was some concern over the food menu; however, it was noted that staff allows for the clients to give suggestions and they will do their best to accommodate them. The STRTP appears to be meeting Core Services/Supports requirements. Due to only the physical plant, and client interviews being completed this inspection will be continued at a later date. No deficiencies were found during this inspection. An exit interview was conducted and a copy of this report was provided to the residential manager Anne Lacy.

met_with: Anne Lacy