summary: Facility Evaluation

raw_content:
Narrative:
On October 05, 2023, Community Care Licensing met with several San Bernardino County agencies, via Microsoft Teams, to discuss the review of the San Bernardino County Transitional Shelter Plan of Operations and Program Statement edits and revisions submitted to Community Care Licensing on July 13, 2023. Children's Residential Program Regional Manager, Lacresha Cook, Licensing Program Manager, Natasha Dunlap, Licensing Program Analyst (LPA) Darlene Oseguera, Systems of Care Analyst, Gina Jones, Provider Policy Implementation Unit Manager, Alcia Bernstein,Program Analyst, Family Intake and Engagement Unit, Adele Carlson, met with Deputy Director, with Rosie Mayzum, Placement Resource Division Manager, Ana Del Nogal, Department of Behavioral Health, Dianne Wokenhauer, Administrator Diana Herrera, Social Service Practitioner's, Amber McChristian and Niccole Sackett. During the meeting the following was discussed: revisions to Application and Supporting Documents, Plan of Operation, Program Statement, Core Services and Supports. The opportunity for questions about the revisions was provided to facility representatives with a summarized review of revisions. The revised plan of operation and program statement, and any application and supportive documentation will be due on October 19, 2023 (per facility request). The following is a summary of the review of the revisions to the Plan of Operation/ Program Statement completed by LPA Darlene Almaraz-Oseguera, Systems of Care (SOC) Policy Analyst Gina Jones, Family Intake Unit Adele Carlson and Julie Waters, and California Foster Care Ombudsperson, Larry Fluharty. CCL Review: Pink Family Intake Unit: Green SOC Review: Orange Foster Care Ombudsman: Blue General Comments: Please highlight the changes you make in the next version of the application so we can easily see the changes we request. Section A: Supportive Documents · LIC500 (any updates) · LIC Administrative Organization · LIC Affidavit Regarding Client Cash Resources · LIC Personnel Record · LIC Criminal Record Statement · LIC C Emergency Disaster Plan · LIC Fire Inspection (pending) · LIC Board of Directors Statement - approved 02/08/2022- copy pending · Copy of admission agreement Introduction (page 3 1st paragraph How many youth will be placed here? Please be more descriptive of type of youth facility will/will not take i.e. medically fragile, feeding tubes, youth that require shots for medication, pregnant teens, etc. B3. Verification of Social Worker Qualifications · page Staffing plan, qualifications and duties Will there always be a supervisor or manager present? · Are there specific duties that some classifications cannot do? For example, can and SSA administer/pass out medication? B6. In-Service Training for Staff · Page CFS - Behavioral Health Crisis Intervention Training -this is listed as an optional training but would be beneficial for TrSCF staff · Page CFS - De-escalating Clients in Crisis- This is listed as an optional training but would be beneficial for TrSCF staff · Page CFS DSS CSEC 101- This is listed as an optional training but would be beneficial for TrSCF staff · Page 15 (last paragraph - Is it 8, 16, or a total of 24? · Page 16 1st sentence - Will the facility do restraints? If so, need more in detail policy. · Page 18 2nd paragraph- Good Information but the flow is confusing. · Page 20 (2nd bullet)- Structured Decision Making SDM) tools (e.g., Family Strengths and needs assessments), This will be phased out after 2024 and the CANS should be utilized · Page 20 (first bullet ) This list should also include: In the case of an Indian child, maintaining connections with the child's tribe and tribal community. · Page 20 (last bullet) This list should also include: In the case of an Indian child, maintaining connections with the child's tribe and tribal community. · Page 23 - under Typical daily schedule & Weekend/non-school days- Please assign times for this B8. Rules of Discipline/Personal Rights · Page Under discipline, Please use trauma informed language such as "taking space" a "feeling break" etc. · Page 29 under Definitions, Missing from Care is a trauma informed phrase used for AWOL · Page 33 under Youth Returning From AWOL- It is more trauma-informed to use the phrase "missing from care". · Page 33 under Contacting Law Enforcement statement, when out of site- This is subjective. Please site examples · Page 34-Visitation will take place in accordance with Juvenile Court approved case plans, and CFS policy on monitoring visits- How does this align with youth becoming assaultive? Admission/Intake: How will you ensure all screening and assessments, including QI assessments and services needed and provided at the shelter, will be documented in the child's file? How will you ensure that this information is entered timely, accurately and is complete? (did not see highlighted in admission or the child file section) How will you work with the county to ensure accurate and timely data entry and documentation in CWS/CMS? (did not see this information) Reporting Requirements and Continuous Quality Control How will the licensee work together to ensure the data is collected and provided to CDSS to understand the need and usage for shelters, reduce the length of stay youth experience in the TrSCF, clarify and eliminate the gaps in the continuum of care, and ultimately reduce the state's reliance on shelter-based care? What methods are in place to ensure continuous quality improvement to understand gaps in services and work with CDSS to reduce reliance on shelters? (Don't see this information) Your reporting requirements section should contain the new requirements around reporting. Please add information on overstay and monthly reports to CDSS in section 86661 (s) (t) and (u). (don't see and don't see III-B-10 either) How will you work with the county to ensure accurate and timely data entry and documentation in CWS/CMS? ( don't see in this section) Discharge and Removal Section 10, pg. How will you ensure a timely written child exit log Per OS 86668.4(f)? (don't see this explained- how will you ensure a timely exit log?) PROGAM POPULATION, SERVICES & CAPABILITIES · Page 42 - last sentence Above pages say 0-18. which ages will be served at facility? PURPOSE, METHODS, GOALS · Page 43 -1st sentence the word temporary- Should this be switched to transitional? CLIENT MEDICAL ASSESSMENTS · Page 49 -4th bullet Not sure how this ties into client medical assessments · Page 50 - 2nd paragraph- Hands on medical care- What if is first aid or CPR? Are there exceptions to not allowing to do any hands on medical care? DISHARGE REMOVAL ·Page 60- 5th bullet- Pre-placement visit- Just making note that often youth need more then 1 pre-placement visit to feel comfortable HOUSE RULES · Page 63 7th bullet - term appropriate clothing- This is subjective. Please give concrete examples · Page 63 10th bullet- smoking - Should also include drinking alcohol and drug use Youth Returning from AWOL · Page 74 & AWOL terms- It is more trauma-informed to use the phrase "missing from care". Limitations and Timelines: Due to the TrSCF placement limitations and the need for the county to secure appropriate placement for a youth, the TrSCF staff, partner agencies and providers must coordinate services to meet the time limits. On page You have created a timeline from the first to last day to ensure that each day there are coordinated efforts to meet the needs of each youth within the required time. Please indicate how you will work to coordinate with your local team to coordinate services in the timeline including schools, regional centers, BCBA and mental health providers and families. How will you build relationship among county entities that will support partnerships and strengthen communication to ensure services and timely placements including interagency placement committees, interagency leadership teams and other individual and system level activities to support you in meeting this timeline. (don't see this discussed) can also mention resources like the state level technical assistance and coaching for complex care youth. See guide: https://www.cdss.ca.gov/Portals/9/CCR/Complex-Care-Guide.pdf Regional Manager, Lacresha Cook, advised that if there was any clarification or questions needed to contact Lacresha Cook, immediately. A copy of this report was emailed to Rosie Mayzum, for signature.

met_with: Rosie Mayzum


state: CA

facility_name: SAN BERNARDINO COUNTY TRANSITIONAL SHELTER

summary: Facility Evaluation

raw_content:
Narrative:
This is an amended LIC809 to the original issued 01/03/2024. On January 03, 2024, at 8:45am, Licensing Program Analysts (LPAs), Darlene Almaraz-Oseguera and Emina Preciado, arrived at the facility for the purpose of conducting pre-licensing inspection at the facility. LPAs were greeted by Deputy Director Rosie Mayzum, Facility Administrator Niccole Sackett, Facility Manager Hugo Castellanos and Facility Manager Christopher Lukachie. This is a single-story home with four bedrooms and three bathrooms. During the inspection, LPAs completed a health and safety inspection and observed the following: Kitchen area with cabinets for snacks. Dining room with tables and chairs for six clients. The smoke and carbon monoxide detectors were tested and are in operable working order during the time of the inspection. The water temperature is no more than 120 degrees and there are no bodies of water on facility grounds. There is a family room with a fireplace, fireplace screen, and recreation space. Sharp objects including knives and cleaning supplies will be stored in a locked kitchen cabinet. Bedroom #1 is set up with two twin beds, closet and dresser space, ample lighting, mattress covers, fitted and flat sheets, comforters, and pillows. Bedroom #2 is set up with two twin beds, closet and dresser space, ample lighting, mattress covers, fitted and flat sheets, comforters, and pillows. Bedroom #3 is set up with two twin beds, dresser space, ample lighting, mattress covers, fitted and flat sheets, comforters, and pillows. This bedroom is missing a door and closet space. Bedroom #4 is set up as a staff office and has a locked closet, staff bathroom and table with four chairs. The medications will be stored in a double locked in the staff office. Client files and staff files will be locked in a file cabinet. The facility outside grounds were also inspected and it was observed to be clean and well maintained. Based on LPA's observations, the following items that are required to be posted were not posted in the facility: Grievance Procedures (OS 86672.2 (a)), Personal Rights (OS 86672(a)), Ombudsman Poster (OS 86672 (a)(1)). In addition, there was no telephone line (OS 86673 (a)) and no first aid kit (OS 80075 (f)). LPA's also observed that bedroom #3 does not have a bedroom door (OS 86687) and there is no closet space (OS 86688 (i)(4)). The required fire clearance approval is also pending. Per Rosie Mayzum, proof of the corrections and copy of the approved fire clearance will be submitted to LPA upon completion. After a final file review, the facility will be submitted for licensure. Exit interview conducted a copy of this report was provided to Rosie Mayzum.

report_type: Facility Evaluation

visit_type: Prelicensing

met_with: Hugo Castellanos


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On July 1, 2025, Community Care Licensing (CCL) met with San Bernardino County (SBC), via Microsoft Teams, to discuss the review of the San Bernardino County Transitional Shelter Care Facility (TrSCF) Program Statement for clarification prior to revisions being re-submitted to CCL. Children's Residential Program Licensing Program Manager (LPM), Jennifer Smith, Licensing Program Analyst (LPA) Val Wilson, met with Deputy Director Project Managment Office, Rosie Mayzum, Staff Analyst II, Corrina Arzola, and Child Welfare Services Manager/Business Lead, Hugo Castellanos . Discussed during the meeting were revisions to Application and Supporting Documents, Plan of Operation, Program Statement, and Core Services and Supports needed in response to the review completed by LPA Wilson. SBC discussed omitting information that was duplicative or no longer applies due to the nonprofit agency contract. The revised plan of operation and program statement, and any application and supportive documentation will be due on July 16, 2025. The opportunity for questions about the noted revisions was provided to facility representatives with a summarized document of the following: • Update LIC 200- Corrina Arzola email received 5/29/25 regarding facility mailing address and a Licensee mailing address. Please use the most recent LIC 200 revised 02/24 and fill out the form to completion. • Update LIC 610C- Add name of the Administrator of facility; Add information required for 111. Facility Exit Locations 1-4; IV. Temporary Relocation Site- submit a letter of permission from Family Assistance Program (You could add another site if SBC TrSCF would like, for Ex. A hotel); V. Utility Shut Off Locations required to be documented; V11. Equipment type of fire alarm sounding device- Location of device(s); V111. Affirmation Statement- Administrator of the facility signature and date. **Continued on page 2** **Continued from page 1** Pg 2 • Update LIC 500- Document who prepared the LIC 500; Who is the Administrator- Identify the Administrator for the facility; Administrator cannot be just "On Call", provide the designated hours "on the premises" which need to align with what is written in your Plan of Operation (POO) and Program Statement (PS); *Note, there are 3 columns and if the Administrator hours vary on different days, those columns are utilized. QUESTION: There are no San Bernardino County (SBC) Social Work or Consultants on the LIC 500, will there be any SBC staff or Specialized staff/Consultants that will be frequenting the facility? I do not see a Family Assistance Program (FAP) Social Worker, but the POO/PS mentions social workers providing many of the supports/services. Corrina clarified SBC SW Liaison Niccole Sackett will be added. PART 1: PROGAM IDENTIFICATION Section 1 • Update Pg 41 bolded "SAN BERNARDINO COUNTY TRANSITIONAL SHELTER (SBTS)" but the name of the facility type is "Transitional Shelter Care Facility". Please add. • Pg 41 remove "seeking licensing for". PS should submit as if the program is in effect. • Pg 41 (and throughout the Plan of Operation (POO) and PS), are the children going to be addressed as "youth", "child"(ren), or "youth/child". There should be consistency throughout the documents (POO & PS). • Pg 41 first two paragraphs please memorialize the following- • Facility is open 24 hours a day, 7 days a week • An individual child may stay in the facility for a 72-hour clock within a 30-day period • Facility is operated by a nonprofit agency contracted with the county • Identity of the nonprofit agency Suggestion- This is a question and not a requirement- has SBC TrSCF considered the possibility of minor parent program that serves minor parents with children younger than six years of age. The reason asked is if not memorialized in both the POO/PS, SBC TrSCF would be out of compliance accepting minor parents with their child(ren). If SBC TrSCF wishes to include this in their program design this could be added here. **Note- the two paragraphs are not a requirement of this section. "Part 1" is IDENTIFY: APPLICANT/LICENSEE NAME & MAILING ADDRESS; PROGRAM NAME; CONTACT PERSON NAME, TITLE & PHONE NUMBER; DOES THE FACILITY OPERATE OTHER ACTIVITIES OTHER THAN TSCFs, AND IF SO, SPECIFY TYPE OF ACTIVITIES; LIST NAME AND ADDRESS OF EACH FACILITY OPERATING THE TSCF PROGRAM Suggestion- Remove and add/collate this information with "Part 11: PROGRAM POPULATION, SERVICES & CAPABILITIES Section 2" statement. **Continued on page 2** **Continued from page 2** Pg 3 • Pg 41 above the box, change Agency to "Licensee" • Pg Contact Person & Title does not match the updated LIC 309 that notes Rosie Mayzum- is it still Jonathan Byers? Please ensure the name on the LIC 309 matches the name provided for Licensee Name and Contact Information. If it is Ms. Mayzum, please provide a LIC 308 and Board Resolution for Ms. Mayzum (See instructions on the top of the LIC 308) • Ms. Arzola's email received 5/29/25 regarding Facility mailing address and a Licensee mailing address- add another row to the box that indicates "Licensee Address" and indicate what that address is. This should match the updates SBC TrSCF is making to the LIC 200 noted in the previous email below (Sent: Friday, June 6, 2025, 5: PM). • Add a box with nonprofit agency name and contact information PART II: PROGAM POPULATION, SERVICES & CAPABILITIES Section 2 (see Pg 42) • Should remove "duration necessary" or keep "duration necessary" and add to the statement "for no longer that the 72-hour clock". • See notations in Section 1 above for Pg 41 "first two paragraphs memorialize the following" and add the same information within the paragraph(s). • Facility is open 24 hours a day, 7 days a week • An individual child may stay in the facility for a 72-hour clock within a 30-day period • Facility is operated by a nonprofit agency contracted with the county • Identity of the nonprofit agency • Pg 42 (and throughout the Plan of Operation (POO) and PS), are the children going to be addressed as youth or child(ren). There should be consistency throughout the full document (POO & PS) • When "SBTS" is mentioned there needs to be clarity who is responsible, and how will they collaborate? Is it SBC TrSCF [licensee] or Family Assistance Program (FAP) [nonprofit agency]. • Define who "county Behavioral Health" is- are they a consultant, a department, SBC Department of Behavioral Health (DBH)? • "CFS" means? Throughout the document, the first time SBC TrSCF provides an acronym, the description will need to be provided. Ex. SBC TrSCF did this in the first sentence with "San Bernardino County Transitional Shelter (SBTS)" • The license and the STD Fire clearance all indicate approval for "6 ambulatory" youth/child(ren)". **Continued on page 4** **Continued from page 3** Pg Please memorialize "6 ambulatory" youth/child(ren)" here. • Regarding "SBTS does not support children with Special Health Care Needs (SHCN)/medically fragile, or children with severe Developmental Disabilities or children under 10 years of age. • "When discussing "severe" Intellectual/Developmental Disability (IDD) clearly identify what is meant, or did SBC TrSCF not mean to use the word "severe". If SBC TrSCF is categorizing IQ levels (mild, moderate, severe, profound), should it then be "severe and profound IDD"? • Regarding Suggestion Section 1 above for Pg 41 bullet 4- if SBC TrSCF does wish to serve "minor parents with children younger than six years of age", this would need to be documented here as part of SBC TrSCF's program design. • The "Part 11: PROGAM POPULATION, SERVICES & CAPABILITIES Section 2" requires the licensee to "Describe the Program Services" (SBC TrSCF Pg Table of Contents indicates PART II includes this information). Please describe the program services. **NOTE- the PS states, "Juvenile Court dependents ages 10-17" and this needs to be consistent throughout the POO/PS. This is also what is indicated on the LIC 200. If this changes at any time as SBC TrSCF revises the POO/PS, please alert the LPA, as it will affect revisions to document and forms. PART III: Purpose, Methods, Goals Section 3 (see Pg 43) • Update Pg 43 "SAN BERNARDINO COUNTY TRANSITIONAL SHELTER (SBTS)" but the name of the facility type is "Transitional Shelter Care Facility". Please correct. • Days and hours of operation needs to be notated • Operated by a nonprofit agency contracted with the county needs to be notated along with the name of the nonprofit agency • Time-limited up to 72 hours should be clarified per regulation 86610(a)(1) "Time-limited up to 72-hour clock within a 30-day period" • "ages 10-17" is mentioned twice and documented on the LIC200; However, mentions assessing 18-year-olds. This would be operating outside of the Plan of Operation (POO)/PS and the facility would be cited. ***NOTE- "up to the age of 18" instead of 17. DEFINITIONS (t)(4) • Mention of 17-year-old turning 18; This could be a request for an extension from CCL and be notated as such if this is what intended. Who (SBC or nonprofit), how, and when will the licensee ensure a request for an extension from CCL will be made **NOTE- this is a time-limited up to 72-hour clock. Will the CCL extension request be prior to placement? **Continued on page 5** **Continued from page 4** Pg 5 • This statement is made twice "Placement in the transitional shelter will be temporary, time-limited of up to 72 hours. A written report will be submitted to California Department of Social Services (CDSS) when the child's placement reaches the 72-hour limit." Is there a reason for repetitive sentences? Suggest removing one. · Update accordingly "when the child's placement reaches 72-hour limit..." REPORTING REQUIREMENTS (s) (1) The licensee shall prepare a written report for each child whose stay in the facility exceeds 72 hours. The licensee shall submit the report to the Department, through a process determined by the Department, no later than 24 hours after the child's placement reaches the 72-hour limit..." · "Jonathan Byers" is notated; However, the name on the updated LIC 309 that notes Rosie Mayzum. Please ensure the name on the LIC 309 matches the name provided for Licensee Name and Contact Information. If it is Ms. Mayzum, please provide a LIC 308 and Board Resolution for Ms. Mayzum (See instructions on the top of the LIC 308) Page 44 · "support to social workers by..." are these SBC or nonprofit social workers? ***NOTE- Please specify for all staff what agency they are from. · RX4Kids Public Health Nurse (PHN) "Providing home-based consulting nursing interventions, and Providing nursing evaluation, information and resources on individual cases."- will they be in the facility? Are they associated in Guardian? Are they the "licensed professional" regarding the written medical and mental health screening no later than 24 hours after acceptance? 86669(a)(1) CLIENT MEDICAL ASSESSMENTS (a)No later than 24 hours after acceptance of a client, the licensee shall obtain a written medical and mental health screening of the child as provided in section 86668.1, which enables the licensee to determine their ability to provide necessary health-related services to the client. (1) The medical and mental health screening shall be performed by a licensed physician or designee, who is also a licensed professional. Please advise and notate accordingly. · "DBH" spell out the first time and put acronym in parentheses · "a screening completed by the social worker" are these SBC or nonprofit social workers? ***NOTE- Please specify for all staff what agency they are from. · "Immediately after admission" ***NOTE- 86669(a)(1) CLIENT MEDICAL ASSESSMENTS (a)No later than 24 hours... Please advise and notate accordingly. **Continued on page 6** **Continued from page 5** Pg 6 · "The CFSSW has access to those reports and the reports from the follow-up services provided as part of the child's CFS case plan." Will nonprofit agency have access and how will they gain access? • Provide a blank copy of form SURF 234 • Provide a blank copy of CANS-IP • "The clinicians will keep a copy of the assessment in the shelter records and will send other copies to the youth social worker and any additional treatment team members. Any immediate findings from the assessment related to safety, supervision, or sleeping arrangements will be immediately conveyed to shelter care staff at the end of the assessment." Clinicians, youth social worker, shelter care staff -are these SBC or nonprofit clinicians? ***NOTE- Please specify for all staff what agency they are from. PART III: Purpose, Methods, Goals Section 3 (see Pg 45) • "The behavioral health clinicians will be either licensed or waivered, and supervised, by a licensed professional. All assessments will be conducted within one business day of admission to the shelter." behavioral health clinicians are these SBC or nonprofit social workers? ***NOTE- Please specify for all staff what agency they are from. one business day of admission to the shelter the written medical and mental health screening no later than 24 hours after acceptance? 86669(a)(1); 24 hours is not the same as "one business day". Please advise and notate accordingly. • This was already memorialized on page 43 from "The primary purpose of the San Bernardino County Transitional Shelter (SBTS).. through ... Children will be placed within the shelter according to age appropriateness and gender identity when not part of a sibling set. No more than two children will be assigned to a room. Placement in SBTS will be temporary, time-limited of up to seventy-two (72)". If keeping in both places, there should be consistency with the previous updates mentioned (see notes for pg 43). If considered redundant, strike out. Page 46 • This was already memorialized on page 43 from "hours. A written report will be submitted to CDSS... through ... CPU provides intensive placement" If keeping in both places, there should be consistency with the previous updates mentioned (see notes for pg 43). If considered redundant, strike out. • This was already memorialized on page 44 "support to social workers by locating appropriate placements for the children... through ...CANS assessment data will be entered into the web-based scoring and report platform so that the scores will be available for ongoing monitoring **Continued on page 7** **Continued from page 6** Pg 7 and outcome measurement." If keeping in both places, there should be consistency with the previous updates mentioned (see notes for pg 43). If considered redundant, strike out. Page 47 • This was already memorialized on page 44 "The clinicians will keep a copy of the assessment ... through ...by a licensed professional. All assessments will be conducted within one business day of admission to the shelter." If keeping in both places, there should be consistency with the previous updates mentioned (see notes for pg 43). If considered redundant, strike out. PART III: Purpose, Methods, Goals Section Planned Activities... (see Pg 47) • The majority of this section appears that it may be out of place and perhaps may be meant for PART III: Purpose, Methods, Goals Section 3 from "Each child will receive a trauma-informed individual initial assessment... through ...The needs and service plan will be updated as needed to document treatment and activities." ***Suggestion- move to the more fitting section for this information and start the section with "Structured indoor and outdoor activities, (e.g., Jesse Turner Center, Jack Bulick park)..." • "Each child will receive a trauma-informed individual initial assessment" what is the title of the person performing this and these SBC or nonprofit employees? ***NOTE- Please specify for all staff a title and what agency they are from. • "Each child will receive... next placement". No statement of 24 hours per 86669(a)(1) CLIENT MEDICAL ASSESSMENTS (a)No later than 24 hours... Please advise and notate accordingly. • "CFS social worker" there is no CFS social worker on the LIC 500. Are they associated in Guardian? Will they be added to the LIC 500? • "Needs and Services Plan (NSP)" per 86668.2(a) and NSP is not required. Will SBC still want to pursue? If yes, what is the title of the person performing the creation of the NSP? And is this SBC or nonprofit employees? ***NOTE- Please specify for all staff a title and what agency they are from. • "CFS will provide all basic needs for the facility." What is it that you are defining here? CCL language is Basic rate or Basic services, or did you mean something else entirely? Please define what this means exactly. • This was already memorialized on page 47 in the first paragraph under the header for Section 4 from "Each child will receive a trauma-informed individual initial assessment... through ...need for transition to his or her next placement." and now restated right above the bullet points. If keeping in both places, there should be consistency with the previous updates mentioned If considered redundant, strike out. **Continued on page 8** **Continued from page 7** Pg 8 • "The child's Case Plan" what exactly is this, please explain. And "reviewed" by who? And is this SBC or nonprofit employees? ***NOTE- Please specify for all staff a title and what agency they are from. • "Procedure to review" Please provide a copy of this procedure or add into this bullet point. • "The needs and service of the Case Plan is reviewed with the child..." by who? And is this SBC or nonprofit employees? • ***NOTE- NSP is not a requirement • "SBTS social worker/Social services staff" is this SBC or nonprofit employees? ***NOTE- Please specify for all staff a title and what agency they are from. • "Structured indoor and outdoor activities, (e.g., Jesse Turner Center, Jack Bulick park)" this list is not a comprehensive listing of community resources. SBC noted " Planned Activities"; however, this will need to be memorialized by a written plan inclusive of the regulation cited. Citing the regulation is not sufficient. And "Children will be offered" by who? And is this SBC or nonprofit employees? The regulation notes a specific requirement 86665(r)(1)(A) ***NOTE- Please specify for all staff a title and what agency they are from. Page 48 • "The child's educational rights holder will be consulted regarding..." is this SBC or nonprofit employees? ***NOTE- Please specify for all staff a title and what agency they are from. • "The school district/school will be contacted..." is this SBC or nonprofit employees? • Space between "consultedregarding" • "Children will have access to laptops or other electronic devices for schoolwork." Who are these devices provided by- SBC or nonprofit- and how and when can they gain access? • "Facility staff will supervise children's attendance..." is this SBC or nonprofit employees? ***NOTE- Please specify for all staff a title and what agency they are from. • "Online tutoring services will be provided as needed to support the child's educational process." How will the child gain access- provided by or signed up for by SBC or nonprofit employees? • Schedule for "weekday", if they do not attend school outside of the facility, what happens between 8am-3pm? This needs to be determined and memorialized here for short school days, holidays or home school type classes. • "6:00 a.m. - Clients will wake up and get ready for the day-Staff to assist with waking clients as age appropriate/morning medication, breakfast" does not quite make sense. Flesh out a bit. **Continued on page 9** **Continued from page 8** Pg 9 • "transport for school/sport activities" is noted on the daily schedules, who is providing the transportation to and from? Is this SBC or nonprofit employees? • As written the "weekday" schedule does not state "planned activities" and this is only noted on "Weekend/non-school days" from 10am- noon; 1-6pm. See PLANNED ACTIVITIES and update • "7-8:30 a.m. - Clients will wake up and get ready for the day-Staff to assist with waking clients as age appropriate/morning medication" does not quite make sense. Flesh out a bit. • "any necessary morning chores" what does this mean? Reminder- Participation in these duties shall be voluntary 86665.2(f) PERSONNEL DUTIES • "10:00 a.m. - Planned activities to include outings.." like what? Please provide the example of TrSCF's monthly calendar of planned outings 86665(r)(1)(A) PERSONNEL REQUIREMENTS • "transitions, staff will go over schedules" is this SBC or nonprofit employees? ***NOTE- Please specify for all staff a title and what agency they are from. • "based on staffing one on one attention may be given to those clients that struggle with the routine" what does this mean? Staffing cannot preclude the needs of a client. Please advise. • "For those clients that refuse school, classwork can be sought out to complete at the shelter" what will sought out to complete at the shelter look like and what staff, SBC or nonprofit employees, will be assigned to do this? Please advise. Page 49 • Age-appropriate chores, learning to assist/cook meals (Independent Living Program - ILP), this needs to be explained what this means. • Provide a blank ILP form • "Activities to be conducted by staff, ILP, outside sources"- staff is who (SBC or nonprofit), explain what is meant by ILP and Outside source. • "Minors to attend based on age and behaviors." Decide on terminology, so far there is child, client and youth and now "minor". This should be ongoing as far as assessment for attendance of all activities of daily living. Why "behaviors" statement here, potential concern regarding personal rights. There is no explanation how and where staff will document the determination, nor what alternative activities will be provided while the other client are on an outing/planned activities. REMINDER- planned outings/planned activities cannot be canceled based on staffing, they are "planned". **Continued on page 10** **Continued from page 10** Pg 11 • Provided a blank HEP • "COVID(-19) status" is mentioned (***NOTE -not a requirement to put in PS, reportable disease/condition under 86661(b) REPORTING REQUIREMENTS ) Are you testing each child? Please advise why this might be mentioned here. • CFS ML 1 form use is mentioned, please provided a copy. ***NOTE - (See attached medication guide for group homes) Is the CFS ML 1 in addition to the LIC 622A medication administration record (MAR) and LIC 622B psychotropic medication administration record (PMAR). • LIC 662A and LIC 622B form copies should be provided based upon above bullet point. • Which staff (SBC or nonprofit agency staff) will assist with self-administration of prescription and nonprescription medications 86675(b) HEALTH-RELATED SERVICES. There is no mention of Centrally Stored Medication and destruction record. Which staff (SBC or nonprofit agency staff) will be responsible? Provide form copy of LIC 622 • ***Note- no mention of vision or hearing devices, adaptive equipment. Please advise and how will this be monitored? • Will there be chance a child is not a dependent or ward of the court? Written authorization of the child's parent or guardian may only be documented when not a dependent or ward of the court ***Note- if the answer is yes, Suggestion- add Written authorization of the child's parent or guardian may only be documented in lieu of a court order if the child is not a dependent or ward of the court Page 51 • "During the child/youth's SBTS stay, CFS must ensure access to all necessary services, including but not limited to:.." 86665. PERSONNEL DUTIES (c) Social work staff shall complete or assist in the completion of the following for each child: (1) An intake assessment, as specified in Section 86668.1, in consideration of the child's medical and mental health screenings. (2) A transition plan. (3) Obtaining, developing and recording of the information necessary for the completion of (1) and (2) above. The LIC 500 and PS Section D do not include a Social Worker or Social Worker job description. Please advise. ***NOTE- Please specify for all staff what agency they are from (SBC or nonprofit agency staff). Medication Procedure..." Elaborate the protocol/procedure. Where in the facility will the medication be stored? Will there be a refrigerator specific to medications that require refrigeration for storage? Where will the LIC 622 and the medications associated ( HEALTH-RELATED SERVICES) be stored and kept? What are the medication administration procedures? What is the protocol for self-administration of medication (SAM) and how much can staff (SBC or nonprofit agency) assist? **Continued on page 12** **Continued from page 11** Pg Will nonprofit agency staff have access to JV 220/JV220A/223? JV's will be needed to fill out the LIC 622B PSYCHOTROPIC MEDICATION ADMINISTRATION RECORD (PMAR), but who will be responsible for ensuring 86675(j) before crating the PMAR? Who creates the LIC 622A MAR or LIC PMAR (See attached medication guide for group homes)? What happens if medication is not properly labeled in compliance with label instructions and state and federal laws and who will be responsible? Who is responsible for identifying there is psychotropic medication and no JV? Who makes the contact for Emergency JV and who would they contact? What about topical treatments? ***NOTE- Please specify for all staff what agency they are from (SBC or nonprofit agency staff). • "Medical/Dental Services:.." "Each child will be referred to a medical facility as needed" What if the child requests to be seen? Who assists with setting this up? Is IEHP the Inland Empire Health Plan (Write out first time to explain the acronym). "CFS partners with IEHP and will engage them in monitoring children's routine medical and dental health as needed." Elaborate how they do this (using a portal?) No discussion of Urgent Care, Emergency Room Visits, 911 or child leaving in an ambulance policy/protocols. Pease advise. Which staff transport if client needs/wishes to be seen? What if the facility vehicle is already is in use elsewhere? Can staff use their own vehicle (reminder, if staff smoke in their personal vehicle it cannot be used to transport clients, even if they do not smoke during the transport)? Will staff (SBC or nonprofit agency) go in the ambulance or follow behind? Will that staff stay in the ER or in the hospital if admitted? ***NOTE- Please specify for all staff what agency they are from (SBC or nonprofit agency staff). • "Educational services" Elaborate, ex. education on medical/dental/mental needs and who would be responsible ? ***NOTE- Please specify for all staff what agency they are from (SBC or nonprofit agency staff). • "Appropriate videoconferencing equipment, etc." What does etc. mean? Please elaborate why this is needed and what it is used for (will all medical needs and assessments be technology based?). Who is responsible for purchasing/maintenance? Perhaps "visitations between the child and family, friends, tribal connections, other important individuals, and the placement care providers to whom the child will be placed... prevailing social and cultural standards of the child's Indian community and/or tribe." Should be under Section Visitation Rules & Policy- Please advise? • "During regularly scheduled work hours RX4Kids Public Health Nurses (PHNs) are available to assist CFS staff with specific duties and client services. The PHNs are required at initial contact or placement to interview the child's parents/relatives/ legal guardians who appear at court on the date of the Detention Hearing... **Continued on page 13** **Continued from page 12** Pg Note: RX4Kids PHNs are unable to assist with medical exams and medication administration, however co-located clinicians may be able to complete assessments and assist in providing resources." Regarding the RX4Kids Public Health Nurses (PHNs) and unable to assist with medical exams, does this mean they will not be providing medical and mental health screening no later than 24 hours after acceptance? Regarding PHN availability, what are the regularly scheduled hours? Does this mean holidays &/or weekends, and please advise who co-located clinicians are and does the nonprofit agency have access to them? ***NOTE- Please specify for all staff what agency they are from (SBC or nonprofit agency staff). Page 52 • CFS staff may administer hands-on medical care on an emergency basis. hands-on medical care on an emergency basis like what/Elaborate? What if nonprofit agency staff provides it? • SBTS clients should be of an age where they can apply their own band aids/ointments with supervision. What if Supervision staff is (SBC or nonprofit agency)? ***Suggestion- move to the more fitting area like page 51 under Medication Procedure for consistency. • "Children needing injections, etc. would need to be able to self-administer. SBTS staff hand them the medication at the time it needs to be administered and then supervise them. If the youth is unable to self-administer SBTS staff will make arrangements with a clinic to ensure they are properly treated." ***Suggestion- Consider adding to PART II: PROGAM POPULATION, SERVICES & CAPABILITIES Section 2 (see Pg 42) if this precludes a child from placement. ***Suggestion- move to the more fitting area like page 51 under Medication Procedure for consistency. ***NOTE- Please specify SBTS staff (SBC or nonprofit agency). make arrangements what does this mean and who would be responsible? • The SBTS supervisor or Lead SSP on that shift is responsible for dispensing/destroying medications. If psychotropic meds are prescribed on an emergency basis, SBTS staff would contact the youth's SW to seek the court order immediately after the fact. Lead SSP is this a Social Service Practitioner (SSP), please define first time in use. SBTS supervisor SBTS staff SBTS liaison ***NOTE- Please specify each of the staff highlighted as SBC or nonprofit agency. ***Suggestion- move to the more fitting area like page 51 under Medication Procedure for consistency. dispensing/destroying medications what is the protocol for destroying medication? Where will it be stored until destroyed and will it remain locked? How will contraband drugs/alcohol be stored and destroyed? contact the youth's SW to seek the court order immediately after the fact where would this be documented? • "Written authorization... if the child in not a dependent or ward of the court or it is documented in the child's record that the county placing agency has verified that the **Continued on page 14** *Continued from page 15** Pg 16 • "Central Placement Unit (CPU) if SBTS is able to accept the youth into the facility:" Incomplete information, CPU for what if SBTS is able? Page 56 • " The youth's gender is compatible with the current residents. The Gender identity of the current residents should be discussed with the SW to ensure all youth will be safe and feel comfortable at the shelter" (OS 86687(n) In every situation where children share a bedroom... bedroom sharing arrangement... When considering compatibility ... what information the child wishes to disclose and to whom... shall not disclose information about the child's sexual orientation and/or gender identity against the child's wishes... documentation shall be maintained in the child's record" ***Note- perhaps say more than what is documented to capture this OS to ensure health and safety. • Provide a blank copy of form CFS- A-1 • Provide a blank copy of the "bedroom sharing arrangement" form that "shall be maintained in the child's record". • "Upon approval for placement, SW arranges for transport of youth" SW? ***NOTE- Please specify for all staff what agency they are from (SBC or nonprofit agency staff). Transport? Who is responsible SBC or nonprofit agency? • Please provide copies of blank forms JV 220; CFS CPS (E/S); CFS CWS; COM004/CFS; COM004.1/ CFS. • "SBTS Intake Staff reviews" Who is this? ***NOTE- Please specify for all staff what agency they are from (SBC or nonprofit agency staff). • Please provide copies of blank forms SOC 154; Acknowledgement of House Rules and Safety procedures (form name/#)? Did you come up with a name/form # yet; CFS D; LIC 621; Contraband Policy • "Children arriving at the SBTS will receive an individualized assessment and health, mental health and developmental screening, and the services necessary to transition the children to their next placement." Per OS 86668.1(a)(3) INTAKE PROCEDURES- The licensee shall provide or coordinate the provision of medical and mental health screenings which shall occur no later than the 24 hours after admission... this should be noted here along with specifically who will be responsible to provide or coordinate the provision of medical and mental health screenings and ensuring it is completed no later than the 24 hours after admission? Please advise ***NOTE- Please specify for all staff what agency they are from (SBC or nonprofit agency staff). **Continued on page 17** *Continued from page 16** Pg 17 • Is placement agreement the same as admission agreement? If not, please provide a blank copy of the placement agreement. If it is the same, consistently call it the same name throughout the POO/PS. • "... shall not exceed 72 hours." 72 hours should be clarified per OS 86610(a)(1) "Time-limited up to 72-hour clock within a 30-day period" • "The SBTS shelter liaison will, in coordination" who is this. ***NOTE- Please specify for all staff what agency they are from (SBC or nonprofit agency staff). Page 57 • Please provide copies of blank form CFS D. • " support to both the STRTP and the placement unit." Is this the same as CPU? CPU was used in the above paragraph. Consistency of placement unit or CPU to avoid uncertainty/confusion. • This section is ADMISSION/INTAKE Section 8. "If there is a youth in the shelter that requires STRTP level of care... Staff assigned to supervise the child/youth will ensure a child/youth will have access to a separate room, separate recreation and separate meal arrangements." This information appear that it might be better suited in the Section Emergency Intervention Plan (EIP), please advise. Perhaps remain memorialized in Section 8 when a child is assessed that their individualized level of care cannot be met at the SBC TrSCF, "If a youth needs to be separated and accommodation within the SBTS cannot be made, staff will make arrangements to secure alternative placement for the child, including housing in the community shelter to await placement." • "If there is a youth in the shelter that requires STRTP level of care, there would need to be vigilant supervision of the youth by the staff in order to keep the other youth safe. This would include separating the youth, if needed, and using de-escalation techniques to work with the youth." What does vigilant supervision mean, please expand. Perhaps identify the different supervision levels used in the facility based on individual health and safety needs (ex. Visual eyes on every 15 minutes, Visual eyes on at all times accept hours of sleep or in their room, Close arm's length, 1 staff remains in common area are examples. Be more specific.) What about mentioning proactive techniques (ex. providing structured activities aimed at promoting active participation in their care to identify and address personal needs, one on one time with staff, etc.) in addition to the reactive (vigilant supervision, de-escalation techniques separating the youth). Again, this information appear that it might be better suited in the Section Emergency Intervention Plan (EIP), see bullet above. **Continued on page 18** **Continued from page 17** Pg Page 58 • "staff" shelter manager" ***NOTE- Please specify for all staff what agency they are from (SBC or nonprofit agency staff). • "entering contact notes within two business days." Why not on the day/shift? The child's stay is time-limited up to 72-hour clock. Please advise • "Safe Measures and case reads" Please explain what these are/define. • This "Contingency Plan" will need to exactly match the POO (OS 86622 (g) 1- PLAN OF OPERATION) Not mentioned is capacity limitation /maximum occupancy established by the fire authority (6 ambulatory clients) 86610(e) LIMITATIONS ON LICENSE, CAPACITY, AND AMBULATORY STATUS • Should the other bullets be under the "contingency plan"? These are the "contingency plan" requirements of OS 86622(g) PLAN OF OPERATION/86610(e) LIMITATIONS ON LICENSE, CAPACITY, AND AMBULATORY STATUS? Please advise • NREFM- please spell out • Consider the bullet "Fire Safety Measures" renamed to be consistent with OS language "fire and life safety measures" please advise; Smoke detectors mentioned but not "carbon monoxide detectors' 86687(m) is not. Please advise. Who is responsible to do for this bullet point? • No mention is made of arrangement for supervision of clients [OS 86622 (g)(1) A process by which the facility will provide sufficient staff as required by Section 86665(a);] • Exit routes on walls- Are the maps/sketches at various locations? Which walls? • "Adapting Physical Facility" OS 86622 (g)(3) A description of the means to adapt the physical features of the facility to accommodate and provide sufficient living space for all children in care; this information is not mentioned in the bullet point. Who is responsible for this bullet point? • "Sign in/out Procedure" define exactly who will be signing in and out on this log. Who is considered a visitor? Will arrival time, date, name, title, child visiting, leave time, staff signature be on the log? Who is responsible for this bullet point? • Please provided a blank copy of the sign in/out log. • Consider adding under "Sign in/out Procedure" adding "please see section VISITATION RULES AND POLICY" to notify the reader where they can find policy on visitors. • "Plan of Correction" This bullet does not state the time limitation of "within 24-hours" OS 86610(e)(2). Please add. Who is responsible for this bullet point? **Continued on page 19** *Continued from page 22** Pg 23 and CFS policy on monitoring visits." Does the policy reflect PERSONAL RIGHTS(c)(8)(A)(1) The child has the right to private visits and contact with the following: Siblings, family members, and relatives. Visits by the child's siblings, family members, and relatives can only be prohibited by court order. Please provide a blank copy of this document/policy. • Does this Admission Agreement policy reflect OS Admission Agreement (c)(5) The facility's policy concerning family visits and other communication with clients, pursuant to Health and Safety Code Section 1512? Does the policy reflect PERSONAL RIGHTS(c)(8)(A)(1) Siblings, family members, and relatives. Visits by the child's siblings, family members, and relatives can only be prohibited by court order. CLIENT RECORDS (h)(7) The placement agency's list of persons who should not be allowed to visit, if available. WIC 16001.9 (a)(12) To visit and contact siblings, family members, and relatives privately, unless prohibited by court order, and to ask the court for visitation with the child's siblings. ADMISSION AGREEMENTS (c)(5) The facility's policy concerning family visits and other communication with clients, pursuant to Health and Safety Code Section 1512. Please provide a blank copy of this document/policy. • "Each child will have access to technology-based visitation and distance learning. Electronic devices used for these purposes will be disinfected between each use, as provided in PIN 20-06-CRP" Are there only going to be technology-based visits? Please advise • Staff, SBTS, SBTS Manager, SBTS staff, SW, carrier SW, assigned SW, shelter administrator, facility administrator, regional worker, regional assigned worker, supervisor, program staff, social worker/CFT, Transitional shelter staff, Shelter staff ***NOTE- Please specify for all staff what agency they are from (SBC or nonprofit agency staff). Please advise. • "An approved contact list shall also be obtained from SW to include significant other(s) the child is allowed to have contact with other than parents/legal guardians. The list is to include individuals with whom the child is not permitted to have contact." conflicts with PERSONAL RIGHTS(c)(8)(A)(1) Siblings, family members, and relatives. Visits by the child's siblings, family members, and relatives can only be prohibited by court order. Remove contact list and highlighted yellow and perhaps add "court prohibited list" or something similar. A list can only by a list of those "prohibited by court order" • A Visitation/contact log- Please provide a blank copy of the log • "Updates to be approved by assigned social worker/CFT." Why is approval needed? PERSONAL RIGHTS(c)(8)(A)(1) Siblings, family members, and relatives. Visits by the child's siblings, family members, and relatives can only be prohibited by court order. Please advise and update.**Continued on page 24** *Continued from page 23** Pg 24 • "staff will ensure youth are available at scheduled visitation times, staff will ensure that youth are able to have access to ways to communicate with family members (or any supportive person in their life." Please list the technology-based devices that are readily available for the children? Is there more than one if another child wants a visit at the same time? How many of each type of device? PERSONAL RIGHTS(c)(8)(A)(1) (8) To have visitors visit privately during waking hours without prior notice, provided that such visitations do not infringe upon the rights of other children; do not disrupt planned activities; and are not prohibited by court order. Siblings, family members, and relatives. Visits by the child's siblings, family members, and relatives can only be prohibited by court order. Please advise and update. Page 64 • Assigned worker, worker, staff, SBTS, SBTS Manager, SBTS staff, SW, carrier SW, assigned SW, shelter administrator, facility administrator, regional worker, regional assigned worker, supervisor, program staff, social worker/CFT, Transitional shelter staff, Shelter staff ***NOTE- Please specify for all staff what agency they are from (SBC or nonprofit agency staff). Please advise. • "communicate with the assigned worker to develop a list of approved individuals that the youth can have phone conversations with, as well as the individuals that they youth will have visitation with, specifically if the visitation can be unsupervised, overnights, or supervised. The worker will also need to communicate the schedule of these visits, again to ensure that the youth is available for these visits." Why is approval needed for private visits if there is no court order? PERSONAL RIGHTS(c)(8)(A)(1) (8) To have visitors visit privately during waking hours without prior notice, provided that such visitations do not infringe upon the rights of other children; do not disrupt planned activities; and are not prohibited by court order. The child has the right to private visits and contact with the following: Siblings, family members, and relatives. Visits by the child's siblings, family members, and relatives can only be prohibited by court order. Please advise and update. • "shelter staff will communicate with the assigned worker regarding any individuals the youth may bring up that they would like to visit with, to determine if this would be appropriate." Why is there a determination if there is no court order? Please advise and update. PERSONAL RIGHTS(c)(8)(A)(1) (8) To have visitors visit privately during waking hours without prior notice, provided that such visitations do not infringe upon the rights of other children; do not disrupt planned activities; and are not prohibited by court order. The child has the right to private visits and contact with the following: Siblings, family members, and relatives. Visits by the child's siblings, family members, and relatives can only be prohibited by court order... Other visitors.**Continued on page 25* *Continued from page 26** Pg 27 • "It is not considered a punishment but rather a brief period for the youth to gather themselves, implement their coping strategies and return without further consequence." Perhaps reword This discipline is a brief period; however, define what specifically is a brief period. • Youth- Decide on terminology, so far there is child, client, youth and minor- remain consistent throughout the document. • The PS copied 86672. DISCIPLINE POLICIES AND PROCEDURES (d) (1-3), but the PS does not memorialize "conditions under which each type of discipline will be used" This must be added along with length of the discipline. keeping in mine Personal Rights. Please update • This bullet also does not memorialize conditions under which each type of discipline will be used- "Prohibition against use of entertainment devices including but not limited to telephones, televisions, personal computers and other internet-enabled" This must be added along with length of the discipline, keeping in mind Personal Rights. Please update Page 70 • These bullets also do not memorialize conditions under which each type of discipline will be used- "devices, video game consoles, radios, portable media players, and stereo equipment. Performance of additional duties related to training needs identified in the child's needs and services plan." This must be added along with length of the discipline, keeping in mind Personal Rights. Please update. • Removal of any communication devices shall contain "Provisions for contact with parents and/or placement representatives (including conferences)." PERSONAL RIGHTS (c)(13) & (c)(8)(A) Please update/advise • Types of discipline not permitted does not mention "violation of personal rights" • "Physical, sexual, emotional, or other abuse"***Suggestion- perhaps add verbal since it is a common complaint/allegation? • Performance of additional duties related to training needs identified in the child's needs and services plan.- can be encouraged or requested PERSONAL RIGHTS, perhaps not appropriate discipline? Please advise • Will there be any positive discipline strategies? EX. Setting Clear Expectations, Reinforce good behavior by offering praise and rewards when your child meets expectations, Encouragement using positive reinforcement to acknowledge and encourage good behavior, spending time to understand their feelings and behavior, Redirecting towards appropriate behavior instead of punishing them for misbehavior. Please advise. **Continued on page 28** *Continued from page 28** Pg 29 • SBTS liaison, Staff, SBTS, SBTS Manager, SBTS staff, SW, carrier SW, assigned SW, shelter administrator, facility administrator, regional worker, regional assigned worker, supervisor, program staff, social worker/CFT, Transitional shelter staff, Shelter staff ***NOTE- Please specify for all staff what agency they are from (SBC or nonprofit agency staff). Please advise. • Security- will there be security at the TrSCF. Please advise. • Separate youth - how will they separate youth? Please advise. • Who (SBC or nonprofit agency staff) contacts SBTS Laision? Please advise. Page 72 • "Prevention is also considered part of the overall engagement practices and developing of a positive culture within the facility." What are other techniques (besides anger de-escalation techniques and verbal prompts that include empathy, listening and mirroring) of group and individual prevention? ***Suggestion- consider GENERAL PROVISIONS (c) The licensee must use a continuum of interventions, starting with the least restrictive intervention. More restrictive interventions may be justified when less restrictive techniques have been attempted and were not effective and the child continues to present an imminent danger for injuring or endangering themselves or others. Please advise. ***Suggestion- Perhaps move this "Preventive measures" section to the start of the EIP leading from least restrictive to more restrictive. • There needs to be a "86722 (e)(6) "Emergency Intervention Staff Training Plan" means a written plan which specifies the training provided to transitional shelter care facility personnel regarding the use of emergency interventions, as specified in Section 86722(g). The emergency intervention staff training plan is a component of the Emergency Intervention Plan." There is not a section named "Emergency Intervention Staff Training Plan" and the "Training in non-violent practices" does not provide specifics of the training provided regarding the use of emergency interventions including (1) The type, title, and a brief description of the training that all facility personnel have completed; (2) Training requirements for new personnel; (3) The ongoing training required for existing personnel; (4) Training curriculum as specified in Section 86765(b); (5) Training schedule which identifies when staff training will be offered and provided; (6) The name(s) and qualification(s) of the instructor(s) who will provide the training and a written test and evaluation criteria for the hands-on competency test. Please advise and update. • All SBTS employees are trained or All staff - does this mean all SBC or nonprofit agency staff? ***NOTE- Please specify for all staff what agency they are from (SBC or nonprofit agency staff). Please advise • SBTS staff meetings, community partners- ***NOTE- Please specify what agency they are occurring/ from (SBC or nonprofit agency staff). Please advise **Continued on page 30** *Continued from page 29** Pg 30 • Please provide a blank copy of CFS A-1 • Youth- Decide on terminology, so far there is child, client, youth and minor- remain consistent throughout the document. • separation room for initial assessments as well as for youth who have escalating behavior.- please use OS terminology "protective separation room". This is not identified on the facility sketch, please identify the room number. What happens if there is more than one child at the same time requiring initial assessments? Per OS 86722. PROTECTIVE SEPARATION ROOM (a)(1) No protective separation room may be used for another purpose, e.g., bedroom, bathroom, storage. (2) No protective separation room may be used without a fire clearance from the local fire authority. ***NOTE: Did the TrSCF get clearance on the room that is declared the "protective separation room"? Please advise • all the requirements of using a protective separation are not met, please read 86722. PROTECTIVE SEPARATION ROOM (a)(5) and the rest of the regulation. Please update/advise • ...de-escalation techniques and will use trauma informed care- does not provide specifics of the training provided as noted in 86722 (e)(6). Please advise Page 73 • Facility Manager/Clinical Case Manager/Executive Director intervention- Are all these people at the TrSCF 24 hours a day (FM must be) and ***NOTE- Please specify what agency they are each from (SBC or nonprofit agency staff). Please advise • A walk with the staff to "cool off" will be utilized- on the facility property or in the neighborhood? • Removal of other youth in the home, when necessary, will occur- how will it be communicated and who makes this decision, and how will they know when to return? • SBTS Binder- where will this binder be kept, who is responsible to document, and at what increments of time is the information logged in? • Please provide a blank copy of the form used in the SBTS binder • Relationship and Positive Culture***Suggestion- Perhaps move this "Preventive measures" section to the start of the EIP leading from least restrictive to more restrictive Page 74 • Please provide a blank copy of the JV220 & CFS YTP 3 • safety separated- is this a typo or please explain **Continued on page 31** *Continued from page 30** Pg 31 • SBTS administrator- ***NOTE- Please specify what agency they are from (SBC or nonprofit agency staff). Please advise • Contacting Law Enforcement (LE) - is the only scenario for LE contact/911 call "a situation become escalated to the point where a client is assaultive and cannot be safety separated without the use of restraint, the staff is to immediately call 911"? what about self-harm, property destruction, etc. Suggestion- perhaps LE contact contains all reasons for contact instead of mention on three different pages 74, 75, and 76? Could be confusing for staff- Please advise? • SBTS staff ratio on many shifts to 1:3, to deal with this possible dilemma- please use specifics, who are the "SBTS staff" counted in the ratio and what does "many shifts" mean? Please advise? Staffing ratio will need an increase if using CPI. Please advise. • Residents, Youth- Decide on terminology, so far there is child, client, youth, minor and residents- remain consistent throughout the document. • Prior to and during a crisis CFT members may be contacted to assist in de-escalating the child/youth.- which CFT members are going to be at the TrSCF? Will this be 24 hours a day? Please advise • CFT members will also, as appropriate, be apprised of incidents that occur at SBTS- Who is designated to make this contact, please advise. • SBTS Laision- ***NOTE- Please specify what agency they are from (SBC or nonprofit agency staff). Please advise • Absent Without Permission- where is the discussion of staff encouraging client to remain at the TrSCF and providing the consequences for leaving? Please advise • if the youth does not return to the facility by dark or is two hours late in returning at night.- Needs to be more specific and not left to interpretation. What is the reason to wait two hours? Page 75 • physically destructive to property other than the facilities- Is there a dollar amount on if it is the facilities or any instance that LE would be called for property destruction in the facility? Please advise • Is not likely to return before dark or the end of the evening.- Needs to be more specific and not left to interpretation. • SBTS Laision, SBTS staff, case carrying social worker (SW), CFT members, Clinical Case Manager- ***NOTE- Please specify what agency they are from (SBC or nonprofit agency staff). Please advise **Continued on page 32** **Continued from page 31** Pg 32 • Community Care Licensing (CCL) and the Child Authorized Representative by the end of the next business day- CCL 24-hour notification can be emailed to our CRP-SIRs email cclpaccr@dss.ca.gov ***Suggest- adding the information • public health nurse- is this the same as previously mentioned RX4Kids Public Health Nurses (PHNs)? Are they available 24 hours a day weekend & holiday? If not, define who will assess. Please advise • Children/youth will be asked if they have any contraband and if so, they will be asked to turn it in.- what if you have a (Reasonable and Prudent Parenting) reasonable suspicion the child may have contraband, define what will happen next. What if the refuse to turn in the contraband, what will happen next. Please advise. Page 76 • The bullet and sub-bullets for "When there is an issue of safety; when a client is a danger to self or others, and the means to carry out a threat is available..."- this is repeated from page 74- please advise • Note: All staff are permitted to contact law enforcement. Law enforcement will only be called as a last resort. - what about imminent danger as described on the first bullet page 76? Please advise • staff would contact emergency personnel to transport the youth to the hospital or would transport the youth to the nearest emergency room to be seen by a medical professional.- ***NOTE- Please specify what agency these people are from (SBC or nonprofit agency staff). Please advise • Youth - Decide on terminology, so far there is child, client, youth, minor and residents- remain consistent throughout the document. • SBTS staff will email the Special Incident Report (SIR) to the Placement Resources Division (PRD), CCL, and the child's/youth's SW within 24 hours of the following occurring:- did you mean the 24hr notification? OS states 7 days but the TrSCF can require this be done faster- Please advise***Suggest- adding the information, Special Incident Report (SIR) LIC624 or LIC 624LE, CCL 24 hour notification can be emailed to our CRP-SIRs email cclpaccr@dss.ca.gov • SW, SBTS staff-***NOTE- Please specify what agency these people are from (SBC or nonprofit agency staff). Please advise • A copy of an SIR- is the TrSCF using the LIC624 and LIC624LE? ***Suggest- adding the information, Special Incident Report (SIR) LIC624 or LIC 624LE to be emailed to our CRP-SIRs email cclpaccr@dss.ca.gov. Please advise • Provide a bank copy of SIR/LIC624 and LIC624LE **Continued on page 33**

Deficiencies:
86672: Siblings, family members, and relatives. Visits by the child's siblings, family members, and relatives can only be prohibited by court order. Please provide a blank copy of this document/policy.
•	Does this Admission Agreement policy reflect OS 86668 Admission Agreement (c)(5)

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
On April 8, 2026, an informal conference was held with San Bernardino County Transitional Shelter (TrSCF) at the Riverside Children's Residential Program Office to discuss outstanding concerns regarding the TrSCF and their provisional license extension. Children's Residential Program Regional Manager, LaCresha Cook; Licensing Program Manager (LPM), Jennifer Smith; Licensing Program Analyst (LPA), Carissa Aviles; Licensing Program Analyst (LPA), Val Wilson, met with Deputy Director PRD, Valerie Croyle; Child Welfare Services Manager, Christina Lopez; and Social Service Practitioner II, Tanajah Steen. LPM Smith discussed the following during the meeting: • Granting an additional 90-day extension to the provisional license with clear expectations for compliance so a permanent license can be approved. The following requirements need to be met: • Governing Body Accountability (ILS Section 84663): For county-operated facilities, the Board of Supervisors serves as the board of directors unless they appoint at least three individuals to the role. All board members must sign and date the LIC 9165 form per Section 84618(h). • Outstanding Information: During our 1/6/26 meeting, the facility agreed to provide the requested board of directors' information by 1/23/26 as set forth in ILS Section 84663; however, this remains outstanding. • Criminal Record Clearance (ILS Section 84619) and Section 1522(b)(1) of the Health and Safety Code: In addition to the applicant, this section shall be applicable to criminal record clearances of all adults responsible for administration or direct supervision of staff. • The facility must submit the outstanding board information and the required signed forms by: April 22, 2026. A copy of this report, 809G, and appeal right was explained and provided to Valerie Croyle.

met_with: Valerie Croyle


summary: Facility Evaluation

raw_content:
Narrative:
On 2/29/2024 at 1:20pm, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the listed facility. The purpose of this visit was to conduct a case management inspection regarding reported allegations regarding food service, transportation, and personal rights. LPA met with John Carr, Social Worker I. At the time of the inspection, there were two clients and two staff members present in the facility. LPA Hood conducted four confidential interviews. LPA received a copy of one client's Individual Crisis Support Plan. LPA will follow up with overseeing Social Work Manager for the other documents. LPA conducted a walk-through of the home. LPA observed that there was a bunk bed in one of the rooms. LPA observed there to be a sufficient amount of perishable and non-perishable food items. LPA conducted an exit interview with John Carr, Social Worker I, at 2:22pm whose signature confirms the receipt of this document.

visit_type: Case Management

met_with: John Carr


summary: Facility Evaluation

raw_content:
Narrative:
On 7/8/2024 at 12:30pm, Licensing Program Analyst (LPA) Selena Hood and LPA Mona Lam conducted an unannounced visit to the unlicensed site. The purpose of this visit was to follow up on concerns regarding the amount of calls to law enforcement, noise levels, and neighborhood relations. LPAs met with John Young, Social Worker I. At the time of the inspection, two youth and two staff members were present in the home. LPAs conducted five confidential interviews. LPAs reviewed the file for one youth in care, centrally stored medication binder, and daily shift reports. LPAs conducted a walk through of the home. LPAs conducted an exit interview with Mary Jane Alvarado, Supervisor at 2:36pm whose signature confirms the receipt of this document.

met_with: Mary Jane Alvarado


summary: Facility Evaluation

raw_content:
Narrative:
On 7/12/2024 at 10:41am, Licensing Program Analyst (LPA) Selena Hood, LPA Mona Lam, and Licensing Program Manager (LPM) Helga Wong conducted an announced visit to the unlicensed site. The purpose of this visit was to conduct the Pre-Licensing inspection. The following attendees were present from Santa Clara County Social Services (SCC): Damion Wright, Gilbert Murillo, John Carr, Erica Kemp, Karen Roberts, Clarence Cisneros Jones, Edwin Garcia, Jackie Mercado, and Daniel Estrada. LPAs and LPM conducted a review of the physical plant. The facility has two client bedrooms, one client bathroom, one staff office, one staff bathroom, and a backyard. The facility had sufficient amount of perishable and non-perishable food items, the facility also receives food service around 8am and 5pm. LPAs and LPM observed that the files and medications were kept in locked cabinets inside the locked staff office. Cleaning supplies were observed to be kept in a locked cabinet inside the garage. The smoke detectors and carbon monoxide detectors were tested and functional during inspection. LPA Lam measured the hot water in the bathroom to reach 124 degrees and the hot water in the kitchen to reach 123 degrees. The facility will send photographic proof of the water temperature as below 120 degrees via email by end of day on 7/15/2024. LPAs and LPM reviewed one staff file. Based on the review, the staff member was missing their updated CPR Certification card. The facility will update the staff file to include the CPR Certification card by end of day on 7/15/2024. LPAs and LPM conducted two confidential interviews. The facility had one client in care at the time of the inspection, the client was on an outing. LPAs and LPM reviewed the client's file. The facility was missing face sheet, discharge plan, and a signature from the client and authorized representative on the personal rights documentation. The facility will provide updated client file via email by the end of day on 7/15/2024. An exit interview was conducted with Gilbert Murillo, Assistant Director and Clarence Cisneros Jones, Manager, at 1:19pm. Assistant Director's signature confirms the receipt of this document.

met_with: Damion Wright


summary: Facility Evaluation

raw_content:
Narrative:
On 7/30/2024 at 10:30am, a virtual meeting was conducted to discuss the Component II and Component III for the facility application. The following attendees were present at the meeting: Nelson Martinez - CCL Regional Manager (RM) Helga Wong - CCL Licensing Program Manager (LPM) Mona Lam - CCL Licensing Program Analyst (LPA) Chadwyck Moore - Program Analyst, System of Care Branch (PM) Gilbert Murillo - Acting Assistant Director of Santa Clara County Department of Family and Children Services Damion Wright - Director of Santa Clara County Department of Family and Children Services Priscilla Mojica-Angulo - Designated Administrator for Morgan Hill and Riverview TrSCF During the meeting, applicant and CCL representatives discussed the TrSCF Operating Standards, Program Statement, and program policies. Incident reporting, safeguarding personal property, basic services, accountability, ratios, personal rights, manual restraints and emergency intervention plan, admission agreements, medical assessment, client/personnel records, register of clients, transportation, health related services, food services, building and grounds, inspection authority, waivers & exceptions, neighborhood policy and community resources, and online resources were discussed during the meeting. LPA Lam shared the Community Care Licensing Division website, Provider Information Notices (PINs), and CARE tools used for TrSCF annuals. The meeting was adjourned at 11:55am. This report will be sent for digital signature.


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Based on observations and interviews, a youth who refused to leave the facility had slept overnight outside the facility. The Department has determined that there is a preponderance of evidence that staff had allowed a youth to sleep outside the facility . Therefore, the above allegation is substantiated. An exit interview was conducted, and appeal rights were discussed with Ms. Garcia. A copy of this report, the LIC Confidential Names, and Appeal Rights were provided via electronic transmission to Program Director, Aiko Yano at 3: PM.

Investigation Findings:
13On January 12, 2024, at 1: PM, Licensing Program Analyst (LPA) Vaishali Singh-Sood made an unannounced visit to the above facility. The purpose of the visit was to re-deliver findings regarding the above allegation. LPA met with Program Assistant, Mariela Garcia who assisted with the visit. On September 26, 2023, The California Department of Social Services (CDSS), Community Care Licensing Division (CCLD) received a complaint alleging Staff allowed youth to sleep outside of facility, overnight at a at the address indicated on the top portion of this report. On October 2, 2023 (10/02/2023), LPA Monica Pavia conducted an onsite inspection and met with the Facility Representative, Heather Lemester to open the investigation. LPA Pavia also received pertinent documents as listed on the LIC 812 form. Additionally, on October 2, 2023, LPA Hood conducted two confidential interviews. LPA Pavia reviewed client records. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Vaishali Singh-Sood 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 26-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, N. First Street, Ste. FACILITY NAME: SENECA FAMILY OF AGENCIES-THE WELCOMING CENTERFACILITY NUMBER: VISIT DATE: 01/12/2024

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

report_type: Complaint Investigation

met_with: Mariela Garcia

complaint_status: SUBSTANTIATED


facility_name: SENECA FAMILY OF AGENCIES-THE WELCOMING CENTER

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Monica Pavia, conducted an unannounced inspection on today's date at 11:15am, and met with Administrator, Jessie Eschman. The facility is licensed for a capacity of 15 ambulatory children, ages 0-17. There are currently no clients residing in the facility. During this inspection, the entire facility was toured. The facility and grounds are in good repair, and free of obstructions. There is adequate indoor activity space and materials. Chemicals are stored in a locked cabinet. Locked and centrally stored medications observed. Adequate storage space observed. Individual beds are in good repair, clean mattresses and pillows observed. Individual beds and crib were observed with appropriate clean linens in good repair. Adequate supply of additional bedding and linens observed. Bedrooms are accommodating of all required furnishings. Adequate food storage space observed. Supply of two days of perishable foods and one week of nonperishable foods observed upon inspection. Weekly menu is posted in the kitchen. All smoke detectors were tested by a fire inspector and appear to be in proper working order. Several fire extinguishers were observed throughout the facility. LPA Pavia reviewed 5 client records and 6 staff records. All files are current and complete. Fingerprint clearances were reviewed using Licensing Information System (LIS) on 9/30/21. All facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances and/or exemptions. There were no Title 22 deficiencies observed during this visit.

met_with: Jessie Eschman


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Monica Pavia met with Jessie Eschman, to discuss an incident where a client's biological mother reported the client reported to her, that a staff "put hands on her". Files were reviewed. Interviews will need to be conducted. This case management inspection will continue.


summary: Facility Evaluation

raw_content:
Narrative:
On 5/25/22 at 8:15am, Licensing Program Analyst (LPA) Monica Pavia conducted an unannounced visit to the above facility. The purpose of this visit was to conduct the required annual inspection. LPA met with Robert Santillan, at the above facility, to conduct the required annual inspection. The facility is a 23 hour and 59 minute transitional facility; it is a two story home, which includes two dayrooms with one alternative dayroom on the first floor; the second floor includes two dayrooms and/or nursery; both floors include offices and open spaces for play/activities; there are three client restrooms; the facility and grounds are in good repair, and free of obstructions; chemicals are stored and locked in the garage; locked and centrally stored medication cabinet observed; observed medication logs; first aid kit complete; individual beds are in good repair; individual beds and crib were observed with clean linens; additional bedding and linens observed; dayrooms are accommodating of all required furnishings; food storage space observed; perishable and nonperishable foods observed; facility does not have a full kitchen so prepared meals are brought in as needed; dining room equipped with tables and chairs accommodating all clients; hot water measured at 138 degrees from kitchen sink; smoke detectors were tested and appear to be in proper working order; fire extinguishers are properly charged; facility maintains a current fire certificate; facility will be using single use paper and plastic at this time, due to COVID; appropriate forms are posted in view of facility clients; facility does not have any open bodies of water; and, no firearms or weapons are allowed in the facility. Staff files were randomly reviewed. All necessary fingerprint clearances were verified on 5/25/22. One staff is fingerprint cleared, however, not associated to this facility. Facility will associate staff today, 5/25/22, to facility 435390025. See Technical Violation attached. Facility has Narcan without a prescription or a waiver to administer. Waiver will be requested today, 5/25/22. See Technical Violation attached. Hot water temperature was turned down during LPA inspection, however, was still reading at 132 degrees. Hot water temperature was turned down again before LPA left the facility. Facility staff will continue to monitor today until hot water temperature is between 105-120 degrees F. Facility staff will randomly check hot water temperature weekly. See Technical Violation attached. There were no Title 22 deficiencies cited during this inspection. Reports were reviewed with Administrator, Jesse Eischman.

met_with: Jesse Eischman


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Monica Pavia met with Jesse Eischman, to close an incident from March 2022, where a client's biological mother reported the client reported to her, that a staff "put hands on her". Interviews were conducted. There were no Title 22 deficiencies cited. This case management inspection is now closed.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Monica Pavia, LPA Selena Hood, Licensing Program Manager (LPM) Carolyn Flynn and Regional Manager (RM) Nelson Martinez made an unannounced site inspection. The purpose of the inspection was to visit a Transitional Shelter Care Facility. Assistant Director, Robert Santillan, facilitated the walk through of the facility. There were no Title 22 deficiencies observed during this inspection.

met_with: Robert Santillan


summary: Facility Evaluation

raw_content:
Narrative:
On May 23, 2023 at 9:00am, Licensing Program Analyst (LPA) Monica Pavia conducted an unannounced visit to the above facility. The purpose of this visit was to conduct the required annual inspection. LPA met with Aiko Yano and Robert Santillan, at the above facility, to conduct the required annual inspection. The facility is a 23 hour and 59 minute transitional facility; it is a two story home, which includes two dayrooms with one alternative dayroom on the first floor; the second floor includes two dayrooms and/or nursery; both floors include offices and open spaces for play/activities; there are three client restrooms; the facility and grounds are in good repair, and free of obstructions; chemicals are stored and locked in the garage; locked and centrally stored medication cabinet observed; observed medication logs; first aid kit complete; individual beds are in good repair; individual beds and crib were observed with clean linens; additional bedding and linens observed; dayrooms are accommodating of all required furnishings; food storage space observed; perishable and nonperishable foods observed; facility does not have a full kitchen so prepared meals are brought in as needed; dining room equipped with tables and chairs accommodating all clients; hot water measured at 106 degrees from kitchen sink; smoke detectors were tested and appear to be in proper working order; fire extinguishers are properly charged; facility maintains a current fire certificate; appropriate forms are posted in view of facility clients; facility does not have any open bodies of water; and, no firearms or weapons are allowed in the facility. Five client files were reviewed. Six staff files were randomly reviewed. All necessary fingerprint clearances were verified on 5/23/23. One staff is fingerprint cleared, however, associated to a different Seneca facility. Staff was associated today, 5/23/23, to facility 435390025, during LPA inspection. See Technical Violation attached. Operating Standards section 80066(a)(8), Personnel Records, states a copy of 'duties of the employee' shall be maintained in each employee file. Facility will add to employee files. See Technical Assistance attached. Operating Standards section 84066(b)(6), Personnel Records, states a copy of 'a record of each work performance evaluation and any correspondence with the employee' shall be maintained in each employee file. Facility will add to employee files. See Technical Assistance attached. Operating Standards section 84065(i)(1)(D)(2), Personnel Requirements, states a copy of 'administrator's assessment if each child care staff understands and can apply the training' shall be maintained in each employee file. Facility will add to employee files. See Technical Assistance attached. There were no Title 22 deficiencies cited during this inspection. Reports were reviewed with Robert Santillan. Reports were emailed to Aiko Yano, Robert Santillan, Jessie Eschman and Matt Cammann.


summary: Facility Evaluation

raw_content:
Narrative:
** Amended - name correction on 10/30/2023 ** On October 27, 2023, at 10: AM, California Department of Social Services CDSS representatives met with Seneca and Santa Clara County over Microsoft Teams for the purpose of conducting an Annual Review. In attendance in this meeting were: - Nelson Martinez - (Community Care Licensing - CCL Regional Manager - RM) - Helga Wong (Licensing Program Manager - LPM) - Carolyn Flynn (Licensing Program Manager- LPM) - Alicia Bernstein (Provider Policy Implementation Unit, Manager - Policy and Technical Assistance Bureau - Systems of Care Branch) - Gina Jones (Provider Policy Implementation Unit, Associate Governmental Program Analyst - Policy and Technical Assistance Bureau - Systems of Care Branch) - Adele Carlson (Associate Government Program Analyst - Child Protection Policy Unit) - Damion Wright (Department of Family and Children's Services - DFCS Director - Administration, Continuum of Care and Intake Operations) - Gilbert Murillo (Department of Family and Children's Services - DFCS Acting Assistant Director) - Matt Cammann (Seneca Regional Executive Director) - Leticia Galyean (Seneca Chief Executive Officer) - Melissa Lawton (Seneca Chief Program Officer) - Aiko Yano (Seneca Program Director) The purpose of the meeting was to discuss Seneca's - The Welcoming Center (TWC) and Santa Clara County Annual Review that was submitted on 9/21/2023. County representatives discussed the actions that Santa Clara County has taken to reduce the number of (Cont. Lic809-c) clients entering the shelter, including engaging with the families early on, working with Behavioral Health, Public Health Nurses, Probation, reaching out to learn more about STRTPs of one/two, and resource family homes, increasing relative placement's. They discussed the building out of their continuum of care, building out hospital divergent programs, and utilizing a "Strike Team." It was discussed how the county is working with San Andrea Regional Center for their clients with disabilities. The county explained that they are working to partner with specific partners such as Seneca who have STRTPs for one/two. The priority is for a community based program but will consider a county run facility. Explanation of the Mockingbird Constellation was provided. Clarification of how overstays are recorded/tracked was given and discussed. Review of Essential Terms and Operating Standards will be done to ensure that all agree of methods used for tracking the time a youth stays at the shelter. Seneca shared that the County's transition to placement for first time removals is very often done within the first 24 hours or often go directly to care. Many of the clients that utilize the shelter need stabilization and individual support. Collaboration with the DHCS and the county is working well and meet daily and hold CFT's weekly. Seneca provides a very "homelike" environment for the client who feel safe and welcomed back when they return to TWC. Seneca will continue to support Santa Clara when the new application is approved and will surrender their license. The Department questioned Santa Clara County, when would a shelter be no longer needed? The county responded that there will always be a need for a shelter. RM reviewed that the license for Seneca Family of Agencies - The Welcoming Center will expire in May 2024 and if an extension is needed that it would need to be requested 30 days prior to expiration in writing. The meeting concluded at 11: AM. No deficiencies were cited during this meeting and a copy of this report is being sent via email to Matt Cammann, Seneca Regional Executive Director, for his signature with a request that a copy of this report be signed and returned to Licensing Program Manger, Carolyn Flynn to file.

met_with: Matt Cammann


facility_name: UMC MOD C

summary: Facility Evaluation

raw_content:
Narrative:
On July 18, 2022, the Department conducted a Technical Assistant meeting via Microsoft Teams with Fresno County. Present in the meeting from Community Care Licensing were, Regional Manager Nelson Martinez, Licensing Program Manager Juanita Arroyo and Licensing Program Analyst Cynthia Galindo. Present from the Family Centered Safety and Support Bureau were Program Analyst Adele Gray and Supervisor Program Analyst Julie Water. Present from Fresno County were Raymundo Zermeno, Rita Bohannon, Christie Lee, and Sharelee Flores. During the meeting, the following was discussed: LPA Galindo and PA Gray discussed the sections that still do not meet the standards, which are sections 10, 13 and 14. Fresno County stated the revisions will be submitted by the end of this week. Fresno County inquired about the Pre-Licensing Inspection expectations. LPM Arroyo discussed insight of what will be inspected. Fresno County is to provide possible dates for the Pre-Licensing Inspection. RM Neslon discussed the next step after the Pre-Licensing Inspection. A copy of this report was emailed to Program Manager, Raymundo Zermeno.

met_with: Fresno County


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Cynthia Galindo, accompanied by Regional Manager Nelson Martinez, Licensing Program Managers Juanita Arroyo and Lourey Bartolome and Program Analyst Adele Gray travelled to the facility listed above to conduct a pre-licensing inspection. Present from Fresno County were Raymundo Zermeno, Rita Bohannon, Christie Lee, Sharelee Flores and Yessica Medina. The facility listed above submitted an application for a Transitional Shelter Care Faility on 02/8/2022. The application and program statement have been reviewed and by both Community Care Licensing and the Systems of Care/ Family Centered Safety and Support Bureau. Facility Inspection conducted. 1. Facility Grounds are clean and free of debris or observable hazard. 2. Adequate indoor and outdoor activity space and materials observed. 3. Chemicals appropriately locked under the kitchen sink. 4. Procedures for locked and centrally stored medications observed. Discussed medication logs and procedures for psychotropic medications. 5. First aid kit observed. Lacks scissors. 6. Storage space is provided- 2 drawers. 7. Individual beds in good repair observed. 8. The facility has 6 bedrooms, single occupancy, all located on one single level. Bedrooms are accommodating of all required furnishings. 9. Adequate food storage space observed. Adequate supply of food to be in place prior to accepting youth for placement. next page... 10. Weekly menu is posted. 11. Dining room equipped with large table and chairs accommodating of all clients. 12. Facility has three full restrooms and one bath in the facility for client use, all are operable. 13. Forms posted- personal rights form with licensing phone number to be posted. 14. No firearms or weapons are allowed in the facility. The following items were discussed and reviewed by LPA during Inspection 1. Reviewed staff schedule to ensure appropriate staffing ratios. More direct care staff to be hired. The facility does not utilize Peer Partners and volunteer at this time. 2. Administrator will be present on-site a minimum of 20 hours per week. 3. Personnel Files are retained at the office and will be available to the department for review upon request. Facility is in the process of setting up guardian account. 4. Facility is to ensure all clients considered for placement have been assessed as meeting placement eligibility requirements. 5. Discussed implementation of Core Services and Supports. 6. Discussed feedback from CFSD and Program Statement revision. 7. Essential Terms and Operating Standards. On this date, this facility is recommended for licensure after the Essential Terms and Operating Standards are completed. Facility will be licensed for a capacity of 6 clients ages 12-17, licensee will maintain age and behavioral compatibility. Facility accepts only ambulatory clients.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analysts (LPAs) Cynthia Galindo and Jessica Rodriguez arrived at the facility and were met by Raymundo Zermeno. LPAs toured the facility. There were no issues or concerns. A copy of the report was left at the facility.

met_with: Raymundo Zermeno


summary: Facility Evaluation

raw_content:
Narrative:
On October 24, 2023, a technical assistance (TA) meeting was held via Microsoft Teams. Present from Fresno County: Kimberli Smith, Rita Bohannon, Raymond Cerda, Bruna Chavez, Jeanette Deleon, Ellieana Ducan, Samrjian Gohar, Marshunda Harding, Novina Holland, Catherine Hueta, Jill Mason, Devendra Patel, Rita Valenzuela, Pamee Thao, Ana Torres-Arana, Peter Vue Present from CCL: Nelson Martinez, Juanita Arroyo, Cynthia Galindo Present from FCSSB: Adele Carlson The purpose of the TA meeting was to discuss the Department's revision letter. Discussed EIP, Job Descriptions, Inservice training for staff and Administration. CCL clarified the Board of Directors and Board of Supervisors. Discussed the Essential Terms, Pub 326, and the steps to finalize the process. The due date for Fresno County's updates is November 27, 2023, but it is subject to change. At the conclusion of the virtual meeting, a copy of this report was emailed to Rita Bohannon for review and signature.

met_with: Rita Bohannon


summary: Facility Evaluation

raw_content:
Narrative:
On November 15, 2023, a technical assistance (TA) meeting was held via Microsoft Teams. Present from Fresno County: Kimberli Smith, Bruna Chavez, Novina Holland, and Christie Lee Present from CCL: Nelson Martinez, Juanita Arroyo, Cynthia Galindo Present from SOC: Chadwyck Moore The purpose of the meeting was to share the Essential Terms (ET). CCL briefly reviewed ET with Fresno County and answered questions. Fresno County said the board will review the ET. CCL said any questions raised by the board on the ET will be forward to Legal. Fresno County said an extension may be needed to submit the program statement updates. At the conclusion of the virtual meeting, a copy of this report was emailed to Fresno County for review and signature. Attachments sent with this report: ACL 17-32, TrSCF Operating Standards v1 and PIN 21-12.

met_with: Kimberli Smith


summary: Facility Evaluation

raw_content:
Narrative:
On May 10, 2024, Licensing Program Analysts (LPAs) Briana Placencia and Angelica Borja, traveled to UMC MOD C for the purpose of a second pre-licensing inspection. Present was Licensing Program Managers Juanita Arroyo and Lourey Bartolome. Present from Fresno County were Deputy Director Dalvin Baker, Division Chief, Rita Bohannan, Social Work Supervisor/Administrator: Marshanda Harding,Division Chief Camille Wilson, Senior Staff Analyst: Pao Yang, Staff Analyst: Jesse Ocegueda-Abarea , Commander Fong Vang, Commander Richard Aguilar, Sergeant Michael Meux. UMC MOD C, submitted an application for a Transitional Shelter Care Facility on February 8, 2022. The application and program statement have been reviewed and by both Community Care Licensing and the Systems of Care/Family Centered Safety and Support Bureau. Facility Inspection conducted. 1. Facility Grounds are clean and free of debris or observable hazard. 2. Adequate indoor and outdoor activity space and materials observed. 3. Procedures for locked and centrally stored medications observed. 4. First aid kit observed. 5. Storage space is provided- 2 drawers. 6. Individual beds in good repair observed. 7. The facility has 6 bedrooms, single occupancy, all located on one single level. Bedrooms are accommodating of all required furnishings. 8. Adequate food storage space observed. Adequate supply of food to be in place prior to accepting youth for placement. 9. Weekly menu is posted. 10. Dining room equipped with large table and chairs accommodating of all clients. 11. Facility has three full restrooms and one shower in the facility for client use, all are operable. 12. Forms posted- personal rights form with licensing phone number. 13. No firearms or weapons were observed in the facility. 14. Water temp read 113.1 degrees. 15. Fire extinguishers were serviced on November 20, 2023. 16. Carbon Monoxide and Smoke detectors were observed and in working order. 17. Facility has an approved fire clearance with the date of April 20, 2022. Facility approved for licensee contingent on receipt of LIC 9165 and LIC 309 for all board members. The facility will receive a copy of this report.