summary: Facility Evaluation

raw_content:
Narrative:
On 1-20-23 11: AM Licensing Program Analysts (LPAs) George Karkazis and Mariah Hawkins conducted an unannounced Case Management /Non-Compliance Conference (NCC) inspection to REFUGE 3, and met with Sylvia Smith, Acting Administrator Ke Ana Elzie Facility Manager. On 07/07/ Community Care Licensing held a Non-compliance conference. The purpose of the inspection was to review the progress of the facility since the facility had their NCC. Immediately after the NCC the facility was not operating and re-opened on 11-30-22. The facility will be on NCC until 11-30-24. Inspections shall occur quarterly. The following conditions were stated and discussed during today's inspection and also during the NCC. 1. Reporting requirements: Facility agrees to create and maintain a written log of all incidents for each client and who the incident reports were sent to. This log will be available for review upon request by the department. Facility agrees to create a plan to conduct an internal review of all documents and will include a review of all incident reports to make sure that they are being completed properly and match up with the internal log of what was sent out. LPA Karkazis observed facility did not have a log established. There have been no incident reports written. An incident report log shall be submitted, an internal review documentation, Wednesday, 2/10/23, emailed to George.Karkazis@DSS.ca.gov 2. Food service: Facility agrees to maintain menu and food supply log to be checked weekly. Facility agrees to provide and alternative menu that allows clients to have food options when what is being served is not preferred or does not meet dietary needs. Fresh fruit and snacks shall be available for the client throughout the day without prior approval needed by staff. Facility agrees to maintain the food supply required by the regulations on a regular basis; 7 day supply of non-perishable food and a 2 day supply of perishable food. Facility agrees to maintain written log that will reflect the above expectations. These expectations are in addition to the regulations that are already established. LPA Karkazis observed 7 day supply of non-perishable food and a 2 day supply of perishable food. This will be available for review at all future NCC inspections. [continued LIC 809-C] continued from LIC 809 *3. Communication with community partners and outside agencies: Facility agrees to submit a plan on how they will have better oversight on communication with community partners and outside agencies. facility agrees to update the land line voicemail and make sure that the voicemail box stays clear regularly. Facility will update program statement to reflect that clients will have access to emails anytime throughout the day. At this time, CCL has not received the plan nor the addendum to the program statement. LPA Karkazis observed that the mailbox is still full. Staff indicated that they need the voicemail code and will obtain it from Administrator. Voicemail box will be checked at future NCC inspections. In addition, the facility agrees to develop a communication logbook (including communication from outside agencies) for the AM, PM, and overnight shifts, and each log will provide line(s) for staff to sign off that they debriefed with the prior shift staff and reviewed the communication log as well as lines at the bottom for the administrator to sign off daily that the communication log was reviewed. The logbook will be available for review at all future NCC inspections. Lastly, the facility agreed to update the program statement to include discussion of permitting residents access to their email when they request, program limitations permitting, and never denying a resident confidential access to their email. LPA Karkazis is requesting the facility to submit both the logbook and the program statement addendum no later than Wednesday, 2/10/23, emailed to George.Karkazis@DSS.ca.gov 4. Client education services / Mental Health services / Needs and Service: In addition to the regulations that have already been established, facility agrees to maintain written record of all progress or decline in clients needs and service. All service notes and mental health information conducted by social work staff shall be kept in the client file and available to for review upon request by the department. All staff will be educated on each client's individual needs and service plan and signature of understanding shall be signed by the staff. The facility agreed to have CFT notes and clinical recommendation maintained in resident files. Additionally, needs and services are updated every thirty days, all staff are trained every thirty days on the updated needs and service plans for each resident, documentation of which with staff signatures will be maintained in training staff file. These items will be reviewed at all NCC inspections. continued on LIC 809-C continued from LIC 809-C 5. Staff training: Facility agrees to have all training's for staff conducted by qualified outside agencies and staff will receive training monthly in order to fulfill the training requirement per regulations. A training log shall me kept at the facility and regularly updated for all staff. The information to be kept in the log shall meet all of the training requirements in the regulations. The training information shall include but not limit; trainer qualifications, training materials, length of training, and signature of attendance. In addition to the training topics listed, facility agrees to hold quarterly training's on personal rights, trauma informed care ( to include de escalation techniques), and medication. Facility states: New hires will receive 24 hours of training before they come on board. Training has occurred on suicidal identification and interventions, and it will continue to be offered regularly. Other training's will be forthcoming, such as positive enforcement and medications. This will take at least one year. The facility is planning on bringing in a Clinical Director to cover training that can't be handled in-house. Training binder was not available for review. LPAs advised that training records be available for the last three years and for each staff's full career with the facility. The facility has hired a Clinical Director, Alber Boles. Additionally, the facility agrees to hold monthly training to meet the 40 hour annual training requirement with trainings every quarter on personal rights, trauma-informed care, de-escalation techniques, and medications. A training log for all staff will be maintained in the training binder that logs all training received each year and training topics, hours, and trainer name, title, and qualifications. Staff signature or certificate as verification of attendance as well as trainer qualifications will be maintained in the training binder. Training binder will be available for review at all future NCC inspections. 6. Emergency Interventions: Facility agrees to submit their emergency intervention plan (EIP) every three months to the department (to their LPA). The facility agreed to conduct a review, every three months, of all intervention methods, their effectiveness, resident response and intended outcomes, and staff implementation and need for training. If the facility identifies any changes to the EIP that are needed, the EIP will be updated and submitted every three months with the EIP review. If no changes are needed and/or further review needed, the EIP will be submitted as is with the EIP review. The first review will be submitted to LPA Karkazis by 2/10/23. continued on LIC 809-C 7. Personal rights: LPAs observed grievance procedures posted and a poster of foster youth bill of rights posted. The poster includes the contact information for Community Care Licensing and the Foster Care Ombudsperson office. The facility agrees to post grievance forms in the facility and to submit a plan on how the facility will conduct weekly meetings with staff and weekly meetings with residents on personal rights, including residents' right to file grievances. The plan will be submitted to LPA Karkazis by Wednesday, 2/8/23, emailed to George.Karkazis@DSS.ca.gov. 8. TSP: Technical Support Program services were offered and facility agrees to submit a response on if they would like to receive this service to LPA Karkazis by 2/10/23. 9. Inspection authority: The facility agrees to have better communication with CCL and provide requested information when requested. The training binder was not available for review during today's inspection, as noted above, and LPAs are issuing an advisory of California Code of Regulations, Title 22, Section Personnel Records, which requires that personnel records be available for review at the facility site. See LIC 9102. 10. Finger print clearance: The facility confirmed understanding that all staff must have a criminal background clearance associated to the facility and has an account set up with Guardian to process background clearance check applications. An exit interview was conducted, appeal rights discussed, and a copy of this report provided to the facility.


state: CA

facility_name: R.E.F.U.G.E.III, THE

summary: Facility Evaluation

raw_content:
Narrative:
On 4/24/23 at 10: AM, Licensing Program Analyst (LPA ) Alyssa Ng and Assistant Program Administrator (APA) Angela Carmack visited listed facility for the purpose of a Psychotropic Medication Inspection. LPA Ng and APA Carmack met with Administrator Khea Gumbs and Alanna Spencer who is the Administrator for a TAY Program. Safety precautions were done such as mask-wearing and temperature checks. Administrator Khea Gumbs stated that there were no clients since March 17, 2023. Facility is working on a contract with the county so no clients are being accepted at this time. Administrator will notify the assigned LPA when there are clients in care. At 10: AM, LPA Ng and APA Carmack did a facility tour inside and out. There are three client bedrooms that were double occupancy. One bathroom was in the front and the second bathroom was located in the client master bedroom in the back of the house. Sharps and staff/client files were located in a locked closet in the backroom. At 10:45, LPA and APA reviewed 1 client file. The file review included the admission agreement, Needs and Service Plan, progress notes, and medication binder. At 11: AM, LPA also went over the facility Inspection checklist, child file review checklist, staff file review checklist, and client and staff interviews. At 12: PM, APA Carmack conducted one staff interview with Administrator. At this time, no deficiencies were cited. An exit interview was conducted and a copy of this report was given to Administrator Khea Gumbs.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Khea Gumbs and Alanna Spencer


summary: Facility Evaluation

raw_content:
Narrative:
On 4-26-23 9:47AM, Licensing Program Analysts George Karkazis and Alyssa Ng conducted an unannounced Annual/Random inspection at listed facility. LPA's met with Khea Gumbs, Facility Administrator and toured the facility inside and out. Safety precautions were taken including screening call and mask wearing. The Short Term Therapeutic Program is licensed to serve six clients. Present during the inspection were one staff member. Currently there are no clients in care, no clients present. At 10:02AM LPA Karkazis and LPA Ng reviewed staff files. There are no clients in placement, no client files were reviewed. Staff 3 did not have a current health screening form. At 10:45AM, LPA Ng and Karkazis toured the facility. LPA Karkazis observed three bedrooms and two bathrooms. LPAs observed facility license, personal rights, facility sketch, meal menu, and other forms posted on the walls throughout the facility. LPA Karkazis tested the water temperature and found it to be 118.9 degrees which is in range. The thermostat read 70 degrees which is within range. Sharps were locked and chemicals were safely stored. There was no perishable food and seven days non-perishable foods present. There are no clients in care. The medication was also stored and locked in a closet, in a locked cabinet.. The facility is in good repair and clean. LPA Karkazis and Ng interviewed one staff and no clients. At 11:03AM LPA Karkazis and Ng toured the backyard. There were no open bodies of water. The backyard was in good repair and clean. continued on LIC 809-C continued from LIC At this time there was a Technical Advisory issued, California Code of Regulations 80066(a)(10) Health Screening form. An exit interview was conducted, appeal rights discussed and a copy of this report was given to Khea Gumbs, Facility Administrator.

visit_type: Annual

met_with: Khea Gumbs, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 4-26-23 11: AM Licensing Program Analysts (LPAs) George Karkazis and Alyssa Ng conducted an unannounced Case Management /Non-Compliance Conference (NCC) inspection to REFUGE 3, and met with Khea Gumbs, Facility Administrator. On 07/07/ Community Care Licensing held a Non-compliance conference. The purpose of the inspection was to review the progress of the facility since the facility had their NCC. Immediately after the NCC the facility was not operating and re-opened on 11-30-22. The facility will be on NCC until 11-30-24. Inspections shall occur quarterly. The following conditions were stated and discussed during today's inspection and also during the NCC. Currently there are no clients in placement as of 03-17-2023. 1. Reporting requirements: Facility agrees to create and maintain a written log of all incidents for each client and who the incident reports were sent to. This log will be available for review upon request by the department. Facility agrees to create a plan to conduct an internal review of all documents and will include a review of all incident reports to make sure that they are being completed properly and match up with the internal log of what was sent out. LPA Karkazis observed that a log book was created with tabs for clients. 2. Food service: Facility agrees to maintain menu and food supply log to be checked weekly. Facility agrees to provide and alternative menu that allows clients to have food options when what is being served is not preferred or does not meet dietary needs. Fresh fruit and snacks shall be available for the client throughout the day without prior approval needed by staff. Facility agrees to maintain the food supply required by the regulations on a regular basis; 7 day supply of non-perishable food and a 2 day supply of perishable food. Facility agrees to maintain written log that will reflect the above expectations. These expectations are in addition to the regulations that are already established. LPA Karkazis observed 7 day supply of non-perishable food. There was no fresh food or menus present, no clients are in placement or present. continued on LIC 809-C continued from LIC 809 *3. Communication with community partners and outside agencies: Facility agrees to submit a plan on how they will have better oversight on communication with community partners and outside agencies. Facility agrees to update the land line voicemail and make sure that the voicemail box stays clear regularly. Facility will update program statement to reflect that clients will have access to emails anytime throughout the day. In addition, the facility agrees to develop a communication logbook (including communication from outside agencies) for the AM, PM, and overnight shifts, and each log will provide line(s) for staff to sign off that they debriefed with the prior shift staff and reviewed the communication log as well as lines at the bottom for the administrator to sign off daily that the communication log was reviewed. The logbook will be available for review at all future NCC inspections. Lastly, the facility agreed to update the program statement to include discussion of permitting residents access to their email when they request, program limitations permitting, and never denying a resident confidential access to their email. LPA Karkazis observed log book and program statement addendum and are on file. Documents received 3-10-23. LPA was able to phone the facility and leave a message. 4. Client education services / Mental Health services / Needs and Service: In addition to the regulations that have already been established, facility agrees to maintain written record of all progress or decline in clients needs and service. All service notes and mental health information conducted by social work staff shall be kept in the client file and available to for review upon request by the department. All staff will be educated on each client's individual needs and service plan and signature of understanding shall be signed by the staff. The facility agreed to have CFT notes and clinical recommendation maintained in resident files. Additionally, needs and services are updated every thirty days, all staff are trained every thirty days on the updated needs and service plans for each resident, documentation of which with staff signatures will be maintained in training staff file. These items will be reviewed at all NCC inspections. Currently there are no clients in placement, no needs and service plans present. continued from LIC 809 5. Staff training: Facility agrees to have all training's for staff conducted by qualified outside agencies and staff will receive training monthly in order to fulfill the training requirement per regulations. A training log shall me kept at the facility and regularly updated for all staff. The information to be kept in the log shall meet all of the training requirements in the regulations. The training information shall include but not limit; trainer qualifications, training materials, length of training, and signature of attendance. In addition to the training topics listed, facility agrees to hold quarterly training's on personal rights, trauma informed care ( to include de escalation techniques), and medication. Facility states: New hires will receive 24 hours of training before they come on board. Training has occurred on suicidal identification and interventions, and it will continue to be offered regularly. Other training's will be forthcoming, such as positive enforcement and medications. This will take at least one year. The facility is planning on bringing in a Clinical Director to cover training that can't be handled in-house. LPAs advised that training records be available for the last three years and for each staff's full career with the facility. The facility has hired a Clinical Director, Abner Boles. Additionally, the facility agrees to hold monthly training to meet the 40 hour annual training requirement with trainings every quarter on personal rights, trauma-informed care, de-escalation techniques, and medications. A training log for all staff will be maintained in the training binder that logs all training received each year and training topics, hours, and trainer name, title, and qualifications. Staff signature or certificate as verification of attendance as well as trainer qualifications will be maintained in the training binder. Training binder will be available for review at all future NCC inspections. LPA observed that the above conditions have been met. 6. Emergency Interventions: Facility agrees to submit their emergency intervention plan (EIP) every three months to the department (to their LPA). The facility agreed to conduct a review, every three months, of all intervention methods, their effectiveness, resident response and intended outcomes, and staff implementation and need for training. If the facility identifies any changes to the EIP that are needed, the EIP will be updated and submitted every three months with the EIP review. If no changes are needed and/or further review needed, the EIP will be submitted as is with the EIP review. Facility has submitted an updated EIP and is on file, received 3-10-23. No changes have been made, there are no clients in care at this time. continued from LIC 809 7. Personal rights: LPAs observed grievance procedures posted and a poster of foster youth bill of rights posted. The poster includes the contact information for Community Care Licensing and the Foster Care Ombudsperson office. The facility agrees to post grievance forms in the facility and to submit a plan on how the facility will conduct weekly meetings with staff and weekly meetings with residents on personal rights, including residents' right to file grievances. The above conditions were fulfilled 3-10-23, and are on file. 8. TSP: Technical Support Program services were offered and facility agrees to submit a response on if they would like to receive this service. Khea Gumbs has declined services at this time. 9. Inspection authority: The facility agrees to have better communication with CCL and provide requested information when requested. Training binder was available on request and reviewed, and in good order. 10. Finger print clearance: The facility confirmed understanding that all staff must have a criminal background clearance associated to the facility and has an account set up with Guardian to process background clearance check applications. An exit interview was conducted, appeal rights discussed, and a copy of this report provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 8-23-23 9: AM Licensing Program Analyst (LPA) George Karkazis conducted an unannounced Case Management /Non-Compliance Conference (NCC) inspection to REFUGE 3, and met with Khea Gumbs, Facility Administrator. On 07/07/ Community Care Licensing held a Non-compliance conference. The purpose of the inspection was to review the progress of the facility since the facility had their NCC. Immediately after the NCC the facility was not operating and re-opened on 11-30-22. The facility will be on NCC until 11-30-24. Inspections shall occur quarterly. The following conditions were stated and discussed during today's inspection and also during the NCC. As of 3-17-23, there were no clients. As of 6-20-23 to the present, there are two clients. 1. Reporting requirements: Facility agrees to create and maintain a written log of all incidents for each client and who the incident reports were sent to. This log will be available for review upon request by the department. Facility agrees to create a plan to conduct an internal review of all documents and will include a review of all incident reports to make sure that they are being completed properly and match up with the internal log of what was sent out. LPA Karkazis observed that a log book was created with tabs for clients. The Administrator stated that there have been no incidents, therefore no incident reports to send. Administrator Gumbs stated that the clients want to reunite with their families and are following their programs, not to jeopardize their reunification. 2. Food service: Facility agrees to maintain menu and food supply log to be checked weekly. Facility agrees to provide and alternative menu that allows clients to have food options when what is being served is not preferred or does not meet dietary needs. Fresh fruit and snacks shall be available for the client throughout the day without prior approval needed by staff. Facility agrees to maintain the food supply required by the regulations on a regular basis; 7 day supply of non-perishable food and a 2 day supply of perishable food. Facility agrees to maintain written log that will reflect the above expectations. These expectations are in addition to the regulations that are already established. LPA Karkazis observed 7 day supply of non-perishable food and a two day supply of perishable food. A current meal meal was posted, with alternative food options. continued on LIC 809-C continued from LIC 809 *3. Communication with community partners and outside agencies: Facility agrees to submit a plan on how they will have better oversight on communication with community partners and outside agencies. Facility agrees to update the land line voicemail and make sure that the voicemail box stays clear regularly. Facility will update program statement to reflect that clients will have access to emails anytime throughout the day. In addition, the facility agrees to develop a communication logbook (including communication from outside agencies) for the AM, PM, and overnight shifts, and each log will provide line(s) for staff to sign off that they debriefed with the prior shift staff and reviewed the communication log as well as lines at the bottom for the administrator to sign off daily that the communication log was reviewed. The logbook will be available for review at all future NCC inspections. Lastly, the facility agreed to update the program statement to include discussion of permitting residents access to their email when they request, program limitations permitting, and never denying a resident confidential access to their email. LPA Karkazis observed log book and program statement addendum and are on file. Documents received 3-10-23. LPA was able to phone the facility and leave a message. In addition, Administrator Gumbs created Daily Residential Note notebook. In addition to the shift notes, this note book contains the client's behaviors, feelings, and events from that shift. It is mandatory for each employee to read these notes before coming on to the shift. 4. Client education services / Mental Health services / Needs and Service: In addition to the regulations that have already been established, facility agrees to maintain written record of all progress or decline in clients needs and service. All service notes and mental health information conducted by social work staff shall be kept in the client file and available to for review upon request by the department. All staff will be educated on each client's individual needs and service plan and signature of understanding shall be signed by the staff. The facility agreed to have CFT notes and clinical recommendation maintained in resident files. Additionally, needs and services are updated every thirty days, all staff are trained every thirty days on the updated needs and service plans for each resident, documentation of which with staff signatures will be maintained in training staff file. These items will be reviewed at all NCC inspections. Currently there are two clients in care. LPA observed current needs and service plans for both clients, one therapy session to be rescheduled, email provided by therapist/administrator. The previous month was present. continued on LIC 809-C continued from LIC 809 5. Staff training: Facility agrees to have all training's for staff conducted by qualified outside agencies and staff will receive training monthly in order to fulfill the training requirement per regulations. A training log shall me kept at the facility and regularly updated for all staff. The information to be kept in the log shall meet all of the training requirements in the regulations. The training information shall include but not limit; trainer qualifications, training materials, length of training, and signature of attendance. In addition to the training topics listed, facility agrees to hold quarterly training's on personal rights, trauma informed care ( to include de escalation techniques), and medication. Facility states: New hires will receive 24 hours of training before they come on board. Training has occurred on suicidal identification and interventions, and it will continue to be offered regularly. Other training's will be forthcoming, such as positive enforcement and medications. This will take at least one year. The facility is planning on bringing in a Clinical Director to cover training that can't be handled in-house. LPAs advised that training records be available for the last three years and for each staff's full career with the facility. The facility has hired a Clinical Director, Abner Boles. Additionally, the facility agrees to hold monthly training to meet the 40 hour annual training requirement with trainings every quarter on personal rights, trauma-informed care, de-escalation techniques, and medications. A training log for all staff will be maintained in the training binder that logs all training received each year and training topics, hours, and trainer name, title, and qualifications. Staff signature or certificate as verification of attendance as well as trainer qualifications will be maintained in the training binder. Training binder will be available for review at all future NCC inspections. LPA observed that the above conditions have been met. 6. Emergency Interventions: Facility agrees to submit their emergency intervention plan (EIP) every three months to the department (to their LPA). The facility agreed to conduct a review, every three months, of all intervention methods, their effectiveness, resident response and intended outcomes, and staff implementation and need for training. If the facility identifies any changes to the EIP that are needed, the EIP will be updated and submitted every three months with the EIP review. If no changes are needed and/or further review needed, the EIP will be submitted as is with the EIP review. Facility has submitted an updated EIP and is on file, received 3-10-23. Two new clients are present as of June/July 2023, there are no changes required with the EIP. Administrator Gumbs has informed LPA that client behavior is stable at this time. continued from LIC 809 7. Personal rights: LPA observed grievance procedures posted and a poster of foster youth bill of rights posted. The poster includes the contact information for Community Care Licensing and the Foster Care Ombudsperson office. The facility agrees to post grievance forms in the facility and to submit a plan on how the facility will conduct weekly meetings with staff and weekly meetings with residents on personal rights, including residents' right to file grievances. The above conditions were fulfilled 3-10-23 , 8-23-23 and are on file. 8. TSP: Technical Support Program services were offered and facility agrees to submit a response on if they would like to receive this service. Khea Gumbs has declined services at this time. 9. Inspection authority: The facility agrees to have better communication with CCL and provide requested information when requested. Training binder was available on request and reviewed, and in good order. 10. Finger print clearance: The facility confirmed understanding that all staff must have a criminal background clearance associated to the facility and has an account set up with Guardian to process background clearance check applications. All staff on duty had fingerprint clearance. An exit interview was conducted, appeal rights discussed, and a copy of this report provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 12-18-23 11:15AM Licensing Program Analyst (LPA) George Karkazis conducted an unannounced Case Management /Non-Compliance Conference (NCC) inspection to REFUGE 3, and met with Khea Gumbs, Facility Administrator. On 07/07/ Community Care Licensing held a Non-compliance conference. The purpose of the inspection was to review the progress of the facility since the facility had their NCC. Immediately after the NCC the facility was not operating and re-opened on 11-30-22. The facility will be on NCC until 11-30-24. Inspections shall occur quarterly. The following conditions were stated and discussed during today's inspection and also during the NCC. As of 11-23-23, there were no clients. Prior, there were two clients. 1. Reporting requirements: Facility agrees to create and maintain a written log of all incidents for each client and who the incident reports were sent to. This log will be available for review upon request by the department. Facility agrees to create a plan to conduct an internal review of all documents and will include a review of all incident reports to make sure that they are being completed properly and match up with the internal log of what was sent out. LPA Karkazis observed that a log book was created with tabs for clients. LPA Karkazis viewed incident reports up to 11-23-23 of two clients. One client did not pass QI, the other transferred back to her county. 2. Food service: Facility agrees to maintain menu and food supply log to be checked weekly. Facility agrees to provide and alternative menu that allows clients to have food options when what is being served is not preferred or does not meet dietary needs. Fresh fruit and snacks shall be available for the client throughout the day without prior approval needed by staff. Facility agrees to maintain the food supply required by the regulations on a regular basis; 7 day supply of non-perishable food and a 2 day supply of perishable food. Facility agrees to maintain written log that will reflect the above expectations. These expectations are in addition to the regulations that are already established. There are no clients in care. LPA toured the kitchen and observed frozen food and non-perishables. A menu was posted and the kitchen was clean and in good order. continued on LIC 809-C continued from LIC 809 *3. Communication with community partners and outside agencies: Facility agrees to submit a plan on how they will have better oversight on communication with community partners and outside agencies. Facility agrees to update the land line voicemail and make sure that the voicemail box stays clear regularly. Facility will update program statement to reflect that clients will have access to emails anytime throughout the day. In addition, the facility agrees to develop a communication logbook (including communication from outside agencies) for the AM, PM, and overnight shifts, and each log will provide line(s) for staff to sign off that they debriefed with the prior shift staff and reviewed the communication log as well as lines at the bottom for the administrator to sign off daily that the communication log was reviewed. The logbook will be available for review at all future NCC inspections. Lastly, the facility agreed to update the program statement to include discussion of permitting residents access to their email when they request, program limitations permitting, and never denying a resident confidential access to their email. LPA Karkazis observed log book and program statement addendum and are on file. Documents received 3-10-23. LPA was able to phone the facility and leave a message. In addition, Administrator Gumbs created Daily Residential Note notebook. In addition to the shift notes, this note book contains the client's behaviors, feelings, and events from that shift. It is mandatory for each employee to read these notes before coming on to the shift. 4. Client education services / Mental Health services / Needs and Service: In addition to the regulations that have already been established, facility agrees to maintain written record of all progress or decline in clients needs and service. All service notes and mental health information conducted by social work staff shall be kept in the client file and available to for review upon request by the department. All staff will be educated on each client's individual needs and service plan and signature of understanding shall be signed by the staff. The facility agreed to have CFT notes and clinical recommendation maintained in resident files. Additionally, needs and services are updated every thirty days, all staff are trained every thirty days on the updated needs and service plans for each resident, documentation of which with staff signatures will be maintained in training staff file. These items will be reviewed at all NCC inspections. Currently there are no clients in care. Archived client files have been moved to headquarter site. continued on LIC 809-C continued from LIC 809 7. Personal rights: LPA observed grievance procedures posted and a poster of foster youth bill of rights posted. The poster includes the contact information for Community Care Licensing and the Foster Care Ombudsperson office. The facility agrees to post grievance forms in the facility and to submit a plan on how the facility will conduct weekly meetings with staff and weekly meetings with residents on personal rights, including residents' right to file grievances. The above conditions were fulfilled 3-10-23 , 8-23-23 and are on file. 8. TSP: Technical Support Program services were offered and facility agrees to submit a response on if they would like to receive this service. Khea Gumbs has declined services at this time. 9. Inspection authority: The facility agrees to have better communication with CCL and provide requested information when requested. 10. Finger print clearance: The facility confirmed understanding that all staff must have a criminal background clearance associated to the facility and has an account set up with Guardian to process background clearance check applications. All staff on duty had fingerprint clearance. An exit interview was conducted, appeal rights discussed, and a copy of this report provided to the facility. continued from LIC 809 5. Staff training: Facility agrees to have all training's for staff conducted by qualified outside agencies and staff will receive training monthly in order to fulfill the training requirement per regulations. A training log shall me kept at the facility and regularly updated for all staff. The information to be kept in the log shall meet all of the training requirements in the regulations. The training information shall include but not limit; trainer qualifications, training materials, length of training, and signature of attendance. In addition to the training topics listed, facility agrees to hold quarterly training's on personal rights, trauma informed care ( to include de escalation techniques), and medication. Facility states: New hires will receive 24 hours of training before they come on board. Training has occurred on suicidal identification and interventions, and it will continue to be offered regularly. Other training's will be forthcoming, such as positive enforcement and medications. This will take at least one year. The facility is planning on bringing in a Clinical Director to cover training that can't be handled in-house. LPAs advised that training records be available for the last three years and for each staff's full career with the facility. The facility has hired a Clinical Director, Jacklyn Smith. Additionally, the facility agrees to hold monthly training to meet the 40 hour annual training requirement with trainings every quarter on personal rights, trauma-informed care, de-escalation techniques, and medications. A training log for all staff will be maintained in the training binder that logs all training received each year and training topics, hours, and trainer name, title, and qualifications. Staff signature or certificate as verification of attendance as well as trainer qualifications will be maintained in the training binder. Training binder will be available for review at all future NCC inspections. Some trainings were conducted via Zoom. LPA observed that the above conditions have been met. 6. Emergency Interventions: Facility agrees to submit their emergency intervention plan (EIP) every three months to the department (to their LPA). The facility agreed to conduct a review, every three months, of all intervention methods, their effectiveness, resident response and intended outcomes, and staff implementation and need for training. If the facility identifies any changes to the EIP that are needed, the EIP will be updated and submitted every three months with the EIP review. If no changes are needed and/or further review needed, the EIP will be submitted as is with the EIP review. Facility has submitted an updated EIP and is on file, received 3-10-23. There are no changes required with the current EIP.


summary: Facility Evaluation

raw_content:
Narrative:
On 4-19-24 9:15AM Licensing Program Analyst (LPA) George Karkazis conducted an unannounced Case Management /Non-Compliance Conference (NCC) inspection to REFUGE 3, and met with Dwayne White, Administrator, Sara Haile, Facility Manager. On 07/07/ Community Care Licensing held a Non-compliance conference. The purpose of the inspection was to review the progress of the facility since the facility had their NCC. Immediately after the NCC the facility was not operating and re-opened on 11-30-22. The facility will be on NCC until 11-30-24. Inspections shall occur quarterly. The following conditions were stated and discussed during today's inspection and also during the NCC. At this time this facility is a 30 day overflow facility for Alameda County. Khea Gumbs is no longer the Administrator. The purpose today's inspection was to reintroduce the terms of this Non-Compliance Conference to the new administrator and facility manager, provide clarification, and check facility progress. 1. Reporting requirements: Facility agrees to create and maintain a written log of all incidents for each client and who the incident reports were sent to. This log will be available for review upon request by the department. Facility agrees to create a plan to conduct an internal review of all documents and will include a review of all incident reports to make sure that they are being completed properly and match up with the internal log of what was sent out. LPA Karkazis observed that a log book was created with tabs for clients. LPA Karkazis viewed incident reports and a log in front. 2. Food service: Facility agrees to maintain menu and food supply log to be checked weekly. Facility agrees to provide and alternative menu that allows clients to have food options when what is being served is not preferred or does not meet dietary needs. Fresh fruit and snacks shall be available for the client throughout the day without prior approval needed by staff. Facility agrees to maintain the food supply required by the regulations on a regular basis; 7 day supply of non-perishable food and a 2 day supply of perishable food. Facility agrees to maintain written log that will reflect the above expectations. These expectations are in addition to the regulations that are already established. There are 2 clients in care. LPA toured the kitchen and observed 7 day supply of non-perishable food and a 2 day supply of perishable food.. A menu was posted and the kitchen was clean and in good repair. continued from LIC 809 *3. Communication with community partners and outside agencies: Facility agrees to submit a plan on how they will have better oversight on communication with community partners and outside agencies. Facility agrees to update the land line voicemail and make sure that the voicemail box stays clear regularly. Facility will update program statement to reflect that clients will have access to emails anytime throughout the day. In addition, the facility agrees to develop a communication logbook (including communication from outside agencies) for the AM, PM, and overnight shifts, and each log will provide line(s) for staff to sign off that they debriefed with the prior shift staff and reviewed the communication log as well as lines at the bottom for the administrator to sign off daily that the communication log was reviewed. The logbook will be available for review at all future NCC inspections. Lastly, the facility agreed to update the program statement to include discussion of permitting residents access to their email when they request, program limitations permitting, and never denying a resident confidential access to their email. LPA Karkazis observed log book and program statement addendum and are on file. Documents received 3-10-23. LPA was able to phone the facility and leave a message. In addition, Administrator White has made shift notes more detailed, which include client behaviors and moods, and a calendar various appointments, and sign in logs, which all match. 4. Client education services / Mental Health services / Needs and Service: In addition to the regulations that have already been established, facility agrees to maintain written record of all progress or decline in clients needs and service. All service notes and mental health information conducted by social work staff shall be kept in the client file and available to for review upon request by the department. All staff will be educated on each client's individual needs and service plan and signature of understanding shall be signed by the staff. The facility agreed to have CFT notes and clinical recommendation maintained in resident files. Additionally, needs and services are updated every thirty days, all staff are trained every thirty days on the updated needs and service plans for each resident, documentation of which with staff signatures will be maintained in training staff file. These items will be reviewed at all NCC inspections. LPA Karkazis observed that clients have current signed needs and service plans. continued on LIC 809-C 5. Staff training: Facility agrees to have all training's for staff conducted by qualified outside agencies and staff will receive training monthly in order to fulfill the training requirement per regulations. A training log shall me kept at the facility and regularly updated for all staff. The information to be kept in the log shall meet all of the training requirements in the regulations. The training information shall include but not limit; trainer qualifications, training materials, length of training, and signature of attendance. In addition to the training topics listed, facility agrees to hold quarterly training's on personal rights, trauma informed care ( to include de escalation techniques), and medication. Facility states: New hires will receive 24 hours of training before they come on board. Training has occurred on suicidal identification and interventions, and it will continue to be offered regularly. Other training's will be forthcoming, such as positive enforcement and medications. This will take at least one year. The facility is planning on bringing in a Clinical Director to cover training that can't be handled in-house. LPAs advised that training records be available for the last three years and for each staff's full career with the facility. The facility has hired a Clinical Director, Jacklyn Smith. Additionally, the facility agrees to hold monthly training to meet the 40 hour annual training requirement with trainings every quarter on personal rights, trauma-informed care, de-escalation techniques, and medications. A training log for all staff will be maintained in the training binder that logs all training received each year and training topics, hours, and trainer name, title, and qualifications. Staff signature or certificate as verification of attendance as well as trainer qualifications will be maintained in the training binder. Training binder will be available for review at all future NCC inspections. Some trainings were conducted via Zoom. LPA observed that the above conditions have been met. Trainings observed : Client Centered and Trauma Focused Approach 4-1-24, Treatment Plans, Assessments, Discharge Summary 4-1-24, Monitoring and Documenting Response to Psychotropic Medications. The above conditions have been met, proof of training viewed via email/DocuSign. LPA advises to keep training sheet in binders, and to update training form dates. 6. Emergency Interventions: Facility agrees to submit their emergency intervention plan (EIP) every three months to the department (to their LPA). The facility agreed to conduct a review, every three months, of all intervention methods, their effectiveness, resident response and intended outcomes, and staff implementation and need for training. If the facility identifies any changes to the EIP that are needed, the EIP will be updated and submitted every three months with the EIP review. If no changes are needed and/or further review needed, the EIP will be submitted as is with the EIP review. Facility has submitted an updated EIP and is on file, received 3-10-23. There are no changes required with the current EIP. continued from LIC 809-C 7. Personal rights: LPA observed grievance procedures posted and a poster of foster youth bill of rights posted. The poster includes the contact information for Community Care Licensing and the Foster Care Ombudsperson office. The facility agrees to post grievance forms in the facility and to submit a plan on how the facility will conduct weekly meetings with staff and weekly meetings with residents on personal rights, including residents' right to file grievances. The above conditions were fulfilled 3-10-23 , 8-23-23 and are on file. 8. TSP: Technical Support Program services were offered and facility agrees to submit a response on if they would like to receive this service. LPA offered and explained TSP Services 9. Inspection authority: The facility agrees to have better communication with CCL and provide requested information when requested. 10. Finger print clearance: The facility confirmed understanding that all staff must have a criminal background clearance associated to the facility and has an account set up with Guardian to process background clearance check applications. All staff on duty had fingerprint clearance. An exit interview was conducted, appeal rights discussed, and a copy of this report provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 4-22-24 9:39AM, Licensing Program Analysts George Karkazis conducted an unannounced Annual/Random inspection at listed facility. LPA met with Dwayne White, Administrator, and toured the facility inside and out. The Short Term Therapeutic Program is licensed to serve 6 clients. Present during the inspection were 2 staff and 1 client. LPA Karkazis requested copies of LIC 500, 610, and 309. At 9:50AM LPA Karkazis reviewed 1 client and 5 staff files. All staff files were complete and in good order. In the client files, C1 was missing a consent form. At 11:35AM LPA Karkazis toured the facility. LPA Karkazis observed 3 bedrooms and 2 bathrooms. LPA observed facility license, personal rights, facility sketch, meal menu, and other forms posted on the walls throughout the facility. LPA Karkazis tested the water temperature and found it to be 116 degrees which is in range. The thermostat read 69 which is within range. Sharps were locked and chemicals were safely stored. There were two days of perishable foods and seven days non-perishable foods present. The medication was also stored and locked in a locked file cabinet, in a locked closet. The facility is in good repair and clean. LPA Karkazis interviewed 1 staff and 1 client. At 12:05PM LPA Karkazis toured the backyard. There were no open bodies of water. The backyard was in good repair and clean. At this time there two deficiencies. A Technical Violation was issued Children's Records Interim Licensing Standards 87070(b)(12), and a citation for National Accreditation ILS 87089(a). An exit interview was conducted, appeal rights discussed and a copy of this report was given to Dwayne White, Administrator.

met_with: Dwayne White, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 5-30-24 12:45PM, Licensing Program Analyst (LPA) George Karkazis conducted an unannounced inspection at REFUGE 3. The purpose of the visit was to ensure that S1, (see LIC Confidential Names List dated 5-30-24), is no longer the Administrator at REFUGE 3. Furthermore, S1 shall no longer be employed/volunteer/work at any Community Care Licensing (CCL) facility, including REFUGE 1 #015600412, REFUGE 2 #015600744, and REFUGE 3 #015650058. LPA met with Dwayne White, Acting Administrator, who helped with the inspection. LPA toured the facility which was clean and in good repair, S1 not present in the facility at the time of inspection. LPA conducted document research in Guardian rosters and found that S1 is still associated to REFUGE 1 #015600412, REFUGE 2 #015600744, and REFUGE 3 #015650058. LPA inspected the posted LIC 500 and found S1 not listed . Dwayne White, Acting Administrator stated that S1's last day of employment was March 21, 2024 . Dwayne White, Acting Administrator stated the reason S1 has not been disassociated from the Guardian rosters is because of a change in Human Resource Directors. HR1 is no longer the Human Resource Director, who was able to make changes in Guardian. The new HR Director HR2 is the only authorized to make changes, and may not know how. Dwayne White, Acting Administrator stated that the Licensee was unable to remove S1 from the Guardian Rosters, yesterday. LPA advises that S1 be disassociated from all REFUGE facilities on Guardian rosters immediately. An exit interview was conducted, and a copy of this report was given to Dwayne White, Acting Administrator.

met_with: Dwayne White, Acting Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 07-03-24 10:15AM Licensing Program Analyst (LPA) George Karkazis conducted an unannounced Case Management /Non-Compliance Conference (NCC) inspection to REFUGE 3, and met with Sara Haile, Facility Manager. On 07/07/ Community Care Licensing held a Non-compliance conference. The purpose of the inspection was to review the progress of the facility since the facility had their NCC. Immediately after the NCC the facility was not operating and re-opened on 11-30-22. Inspections shall occur quarterly. The following conditions were stated and discussed during today's inspection and also during the NCC. At this time this facility is a 30 day overflow facility for Alameda County. The purpose today's inspection was to check facility progress. Present were two staff and two clients. 1. Reporting requirements: Facility agrees to create and maintain a written log of all incidents for each client and who the incident reports were sent to. This log will be available for review upon request by the department. Facility agrees to create a plan to conduct an internal review of all documents and will include a review of all incident reports to make sure that they are being completed properly and match up with the internal log of what was sent out. LPA Karkazis observed that a log book was created with tabs for clients. LPA Karkazis viewed incident reports and a log in front. This condition has been met and fulfilled. 2. Food service: Facility agrees to maintain menu and food supply log to be checked weekly. Facility agrees to provide and alternative menu that allows clients to have food options when what is being served is not preferred or does not meet dietary needs. Fresh fruit and snacks shall be available for the client throughout the day without prior approval needed by staff. Facility agrees to maintain the food supply required by the regulations on a regular basis; 7 day supply of non-perishable food and a 2 day supply of perishable food. Facility agrees to maintain written log that will reflect the above expectations. These expectations are in addition to the regulations that are already established. LPA toured the kitchen and observed 7 day supply of non-perishable food and a 2 day supply of perishable food.. A menu was posted and the kitchen was clean and in good repair. This condition has been met and fulfilled. continued on LIC 809-C continued from LIC 809 *3. Communication with community partners and outside agencies: Facility agrees to submit a plan on how they will have better oversight on communication with community partners and outside agencies. Facility agrees to update the land line voicemail and make sure that the voicemail box stays clear regularly. Facility will update program statement to reflect that clients will have access to emails anytime throughout the day. In addition, the facility agrees to develop a communication logbook (including communication from outside agencies) for the AM, PM, and overnight shifts, and each log will provide line(s) for staff to sign off that they debriefed with the prior shift staff and reviewed the communication log as well as lines at the bottom for the administrator to sign off daily that the communication log was reviewed. The logbook will be available for review at all future NCC inspections. Lastly, the facility agreed to update the program statement to include discussion of permitting residents access to their email when they request, program limitations permitting, and never denying a resident confidential access to their email. LPA Karkazis observed log book and program statement addendum and are on file. Documents received 3-10-23. LPA was able to phone the facility and leave a message. In addition, Facility Manager has made shift notes more detailed, which include client behaviors and moods, and a calendar various appointments, and sign in logs, which all match. This condition has been met and fulfilled. 4. Client education services / Mental Health services / Needs and Service: In addition to the regulations that have already been established, facility agrees to maintain written record of all progress or decline in clients needs and service. All service notes and mental health information conducted by social work staff shall be kept in the client file and available to for review upon request by the department. All staff will be educated on each client's individual needs and service plan and signature of understanding shall be signed by the staff. The facility agreed to have CFT notes and clinical recommendation maintained in resident files. Additionally, needs and services are updated every thirty days, all staff are trained every thirty days on the updated needs and service plans for each resident, documentation of which with staff signatures will be maintained in training staff file. These items will be reviewed at all NCC inspections. LPA Karkazis observed that clients have current signed needs and service plans, assessments conducted for clients staying a maximum of 30 days. This condition has been met and fulfilled. continued on LIC 809-C continued from LIC 809 7. Personal rights: LPA observed grievance procedures posted and a poster of foster youth bill of rights posted. The poster includes the contact information for Community Care Licensing and the Foster Care Ombudsperson office. The facility agrees to post grievance forms in the facility and to submit a plan on how the facility will conduct weekly meetings with staff and weekly meetings with residents on personal rights, including residents' right to file grievances. The above conditions were fulfilled 3-10-23 , 8-23-23 and are on file. 8. TSP: Technical Support Program services were offered and facility agrees to submit a response on if they would like to receive this service. LPA offered TSP services, Facility Manager Sara Haile declined. 9. Inspection authority: The facility agrees to have better communication with CCL and provide requested information when requested. 10. Finger print clearance: The facility confirmed understanding that all staff must have a criminal background clearance associated to the facility and has an account set up with Guardian to process background clearance check applications. All staff on duty had fingerprint clearance. The facility has met all conditions of the Non-Compliance Conference which started on 7-7-22. Quarterly inspections shall cease and REFUGE 3 is no longer on Non-Compliance as of 7-3-24. An exit interview was conducted, appeal rights discussed, and a copy of this report provided to the facility. continued from LIC 809 5. Staff training: Facility agrees to have all training's for staff conducted by qualified outside agencies and staff will receive training monthly in order to fulfill the training requirement per regulations. A training log shall me kept at the facility and regularly updated for all staff. The information to be kept in the log shall meet all of the training requirements in the regulations. The training information shall include but not limit; trainer qualifications, training materials, length of training, and signature of attendance. In addition to the training topics listed, facility agrees to hold quarterly training's on personal rights, trauma informed care ( to include de escalation techniques), and medication. Facility states: New hires will receive 24 hours of training before they come on board. Training has occurred on suicidal identification and interventions, and it will continue to be offered regularly. Other training's will be forthcoming, such as positive enforcement and medications. This will take at least one year. The facility is planning on bringing in a Clinical Director to cover training that can't be handled in-house. LPAs advised that training records be available for the last three years and for each staff's full career with the facility. The facility has hired a Clinical Director, Jacklyn Smith. Additionally, the facility agrees to hold monthly training to meet the 40 hour annual training requirement with trainings every quarter on personal rights, trauma-informed care, de-escalation techniques, and medications. A training log for all staff will be maintained in the training binder that logs all training received each year and training topics, hours, and trainer name, title, and qualifications. Staff signature or certificate as verification of attendance as well as trainer qualifications will be maintained in the training binder. Training binder will be available for review at all future NCC inspections. Some trainings were conducted via Zoom. LPA observed that the above conditions have been met. Trainings observed : Suicide Prevention Techniques 6-26-24, 6-13- Meal Count Training, 4-13- Medication Training 4-13-14. This condition has been met and fulfilled 6. Emergency Interventions: Facility agrees to submit their emergency intervention plan (EIP) every three months to the department (to their LPA). The facility agreed to conduct a review, every three months, of all intervention methods, their effectiveness, resident response and intended outcomes, and staff implementation and need for training. If the facility identifies any changes to the EIP that are needed, the EIP will be updated and submitted every three months with the EIP review. If no changes are needed and/or further review needed, the EIP will be submitted as is with the EIP review. Facility has submitted an updated EIP and is on file, received 3-10-23. There are no changes required with the current EIP. This condition has been met and fulfilled


summary: Facility Evaluation

raw_content:
Narrative:
On 4/22/25, Licensing Program Analysts (LPAs) Celeste Aparicio made an announced collateral visit to the facility to conduct a confidential interview. LPA met with Janala Major, Direct Care Staff and informed Direct Care Staff on the purpose of the visit. LPA conducted one client confidential interview related to an outside investigation. An exit interview was conducted, and a copy of this report was left with, Direct Care Staff whose signature on this form confirms receipt.

met_with: Direct Care Staff, Janala Major


summary: Facility Evaluation

raw_content:
Narrative:
Control #: 2036-FN, 2037-FN On August 7, 2025 at 11: AM Licensing Program Analyst (LPA), Omar Sawyer and Licensing Program Analyst (LPA), Monica Pavia, made an unannounced visit to R.E.F.U.G.E. III facility for the purpose of conducting a case management inspection regarding an Incident Report Follow-Up dated 07/29/2025 involving Client 1 (C1) and Client 2 (C2). (see LIC Confidential Names List dated 08/07/25). LPA Sawyer and LPA Pavia met with Program Supervisor, Dwayne White (S3). There are two clients in care currently present. LPA Sawyer requested Staff Roster and Staff Schedule to cross reference staffing on the day of initial Incident Report. Based on a review of the incident report received by the department, the facility did not provide information on a plan moving forward for the clients. Clarification was needed regarding how this incident occurred as the description did not provide all pertinent information, as well as the plan for both clients moving forward, how will staff ensure that clients feel safe and prevent an event like from occurring again, and what was done with the pepper spray. During the conversation with Mr. White, follow up information was given regarding the aforementioned issues. Pepper spray was confiscated and meeting was held with youth in care. An exit interview was conducted, and a copy of this report was given to Program Supervisor Dwayne White, whose signature confirms receipt.

met_with: Program Supervisor Dwayne White, Sheena Moore, Direct Care Counselor


summary: Facility Evaluation

raw_content:
Narrative:
On 11-13-23 12:00PM, Licensing Program Analyst (LPA) George Karkazis conducted an unannounced inspection and met with Khea Gumbs, Administrator. The purpose of the inspection was to conduct a case management regarding incident reports. On November 8, 2023 1:28PM, facility sent three incident reports to the San Bruno Incident Report Inbox. All three were all marked "late" by the officer on duty. Administrator discussed the reason for late reports sent to the department with LPA. Reporting requirements were discussed with administrator. At this time a Technical Violation is being issued. Title 22, Division 6, Chapter 1, Article Reporting Requirements 80061(b) An exit interview was conducted, appeal rights discussed, and a copy of this amended report was given to Dawayne White whose signature confirms receipt.

met_with: Khea Gumbs, Administrator


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Investigation Findings:
13On December 4, 2025 at 11: AM, Licensing Program Analyst (LPA) Omar Sawyer and LPA Shikya Belfield made an unannounced inspection to the above facility. The purpose of this inspection is to inform the facility representative of the findings regarding the above allegations. LPA met with Dwayne White, Administrative Supervisor and Marla Anderson, Program Director, who assisted with this inspection. Based on confidential interviews and documentation review. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. Therefore, this allegation is Unsubstantiated. An exit interview was conducted and a copy of this report along with appeal rights was left with Dwayne White, Administrative Supervisor. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Omar Sawyer LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

report_type: Complaint Investigation

met_with: Dwayne White, Administrative Supervisor

complaint_status: unsubstantiated


raw_content:
Investigation Findings:
13*** Investigation was reconducted and new findings delivered on 12/29/25. On December 29, 2025 at 11: AM, Licensing Program Analyst (LPA) Omar Sawyer and LPA Paul Simien made an unannounced inspection to the above facility. The purpose of this inspection is to amend this complaint and inform the facility representative of the findings regarding the above allegations. LPA met with Dwayne White, Administrative Supervisor. Based on confidential interviews and supportive photographs, and observations. Staff physically assaulted client in care, Program does not allow clients to attend school of origin, Staff do not ensure that medication is readily available to clients, Facility is not addressing safety concerns of clients, Facility does not provide appropriate personal hygiene items. The preponderance of the evidence has been met. Therefore, these allegations are Substantiated. Facility is being cited for violation of Interim Licensing Standards, Section, 87072(c)(1), 87072(d)(27), 87072(c)(16), and California Code of Regulations, Title 22, Division Six, Section 80075(b) Health related services, as described on the following LIC 9099-D. Civil pentalties are being assessed for Staff physically assaulting client in care and also for Staff not ensuring that medication is readily available to clients. An exit interview was conducted, a plan of correction (POC) was developed, appeal rights were provided, and a copy of this report was left with Mr. Dwayne White, Administrative Supervisor whose signature on this form confirms receipt. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Omar Sawyer 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 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE This is an official report of an unannounced visit/investigation of a complaint received in our office on 10/23/2025 and conducted by Evaluator Omar Sawyer PUBLICCOMPLAINT CONTROL NUMBER: 14-CR- FACILITY NAME:R.E.F.U.G.E.III, THEFACILITY NUMBER: ADMINISTRATOR:BRITTANY FLENTROYFACILITY TYPE: ADDRESS: LOMA VISTA AVENUETELEPHONE: (510) 530- CITY:OAKLANDSTATE: CAZIP CODE: CAPACITY:6CENSUS: 3DATE: 12/04/ UNANNOUNCEDTIME BEGAN: 12: PM MET WITH:Dwayne White, Administrative SupervisorTIME COMPLETED:02: PM 9Staff did not provide trauma informed care and supervision Staff retaliated against clients in care Staff are supervising clients while under the influence INVESTIGATION FINDINGS: 13*** Investigation was reconducted and new findings delivered on 12/29/25. On December 29, 2025 at 11: AM, Licensing Program Analyst (LPA) Omar Sawyer and LPA Paul Simien made an unannounced inspection to the above facility. The purpose of this inspection is to amend this complaint and inform the facility representative of the findings regarding the above allegations. LPA met with Dwayne White, Administrative Supervisor, who assisted with this inspection. Based on confidential interviews and supportive documentation including emails and text messages the allegations, "Staff did not provide trauma informed care and supervision,", "Staff retaliated against clients in care," and "Staff are supervising clients while under the influence," had inconsistent results, therefore they are determined to be unsubstantiated. Although the allegations may have happened or is valid, there is not a perponderance of the evidence. Therefore, these allegations are Unsubstantiated. An exit interview was conducted and a copy of this report along with appeal rights was left with Mr. Dwayne White. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Omar Sawyer 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: 2 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., Suite San Bruno, CA Facility Name: R.E.F.U.G.E.III, THEFACILITY NUMBER: 015650058

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


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Investigation Findings:
13**On 12/31/25 findings are being redelivered by Licensing Program Analyst (LPA) Omar Sawyer and LPA Shikya Belfield. ***Investigation was reconducted and new findings delivered on 12/29/25. Based on further review this report is being amended to reflect changes in amendment findings and individuals present during the inspection. On December 29, 2025 at 11: AM, Licensing Program Analyst (LPA) Omar Sawyer and LPA Paul Simien made an unannounced inspection to the above facility. The purpose of this inspection is to inform the facility representative of the findings regarding the above allegations. LPA met with Dwayne White, Administrative Supervisor, who assisted with this inspection. Based on confidential interviews, a review of facility program statement, photographs, and LPA observations. The allegations "Staff did not attempt to de-escalate minor in care", and "Staff yelled and spoke to clients in an inappropriate manner" are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violations did or did not occur. Therefore, these allegations are Unsubstantiated. An exit interview was conducted and a copy of this report along with appeal rights was left with Administrative supervisor Dawayne White, whose signature confirms receipt. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Omar Sawyer 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 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE This is an official report of an unannounced visit/investigation of a complaint received in our office on 10/20/2025 and conducted by Evaluator Shikya Belfield COMPLAINT CONTROL NUMBER: 14-CR- FACILITY NAME:R.E.F.U.G.E.III, THEFACILITY NUMBER: ADMINISTRATOR:BRITTANY FLENTROYFACILITY TYPE: ADDRESS: LOMA VISTA AVENUETELEPHONE: (510) 530- CITY:OAKLANDSTATE: CAZIP CODE: CAPACITY:6CENSUS: 3DATE: 12/04/ UNANNOUNCEDTIME BEGAN: 11: AM MET WITH:Dawayne WhiteTIME COMPLETED:01: PM 9Staff does not provide adequate supervision resulting in minor engaging in inappropriate behavior. INVESTIGATION FINDINGS: 13On December 4, 2025 at 11: AM, Licensing Program Analyst (LPA) Omar Sawyer and LPA Shikya Belfield made an unannounced inspection to the above facility. The purpose of this inspection is to inform the facility representative of the findings regarding the above allegations. LPA met with Dwayne White, Administrative Supervisor and Marla Anderson, Program Director who assisted with this inspection. Based on confidential interviews, a review of facility program statement, and photographs, Although the violation may have happened or is valid, there is not a perponderance the evidence to prove that Staff does not provide adequate supervision resulting in minor engaging in inappropriate behavior. Therefore this allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was left with Administrative supervisor Dawayne White, whose signature confirms receipt. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Shikya Belfield 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: 2 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., Suite San Bruno, CA Facility Name: R.E.F.U.G.E.III, THEFACILITY NUMBER: 015650058

Allegations:
- UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion: UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 90

met_with: Dawayne White


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Alyssa and Licensing Program Manager (LPM) Carolyn on 2/23/22 at 11:00AM. During the inspection, LPA Ng and LPM Flynn met with Geneva Morgan, Program Trainer and inspected the facility inside and out. LPA reviewed 3 of child's records on site at the facility at 11: PM. LPA reviewed 2 of staff personnel files on site at the facility at 1: PM. LPA reviewed 3 of child's psychotropic medications and medication records at 12: PM. LPA interviewed 2 of staff on site at 1: PM. LPA interviewed 3 of children currently taking psychotropic medication at 2: PM. LPA conducted exit interview with Geneva Morgan, Program Trainer at 3: PM. LPA provided the Summary Report to Geneva Morgan, Program Trainer upon completion. One deficiency was observed (refer to LIC 809D) and cited from the California Code of Regulations, Title 22, and Health & Safety Codes during the inspection. LPA conducted exit interview with Geneva Morgan, Program Trainer at 3: PM.

met_with: Geneva Morgan


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst's (LPA) Shikya Belfield and Lisa Schlembach made an unannounced inspection to the above facility on 4/22/2022 at 12: PM. The purpose for this inspection is to conduct a case management. LPA's Belfield and Schlembach met with Direct care staff Carmen Lee who assisted with the visit. A walk through of the facility was conducted with these LPA's and staff Lee. During the walk through, the facility was observed to be clean and in good repair. During this walk through, LPA Belfield took photographs of the bedrooms, and the common areas of the facility. LPA's observed bedroom 3 that has a bathroom connected to it. LPA asked staff Lee which bathroom does staff use. Staff Lee informed these LPA's that they staff uses the bathroom in bedroom 3. Facility cited for violation of section 87087(b)(5) Buildings and Grounds. Based on a review of the in the Licensing Information System, facility roster and facility staff schedule, it was discovered that 8 staff on the schedule and staff roster for the facility are not associated to the facility and 3 staff do not have criminal record clearance to work. Administrator Khea Gumbs called LPA's Schlembach's phone at 12: PM. LPA's discussed with administrator Gumbs and staff Lee and asked them if the program has a current waiver on file with the department regarding criminal record clearances. Both administrator and staff Lee stated they did not know and were not sure. Facility is being cited for violation of the Short Term Residential Therapeutic Program, Interim Licensing Standards (ILS), Version 4: 80019(e)(1): Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. During this inspection, LPA's Belfield and Schlembach experienced technical issues with their equipment. Facility staff Lee and administrator were informed that the documents and information regarding this inspection would be sent via email for their review and signature. Advisory Issued for association of 8 staff ( see LIC 811 dated 4.22.2022) and facility cited for violation of section 80019(e)(1) as S6, S7, and S8 have no criminal record clearance to work. Immediate civil penalties were assessed. Advisories Issued. Facility cited for violation of the Interim Licensing Standards, Section 80019(e)(1): Criminal Record and Section 87087(b)(5) Buildings and Grounds. An exit interview was conducted with staff Lee and a copy of this report along with appeal rights will be sent to staff Lee and administrator Gumbs via email.

met_with: Carmen Lee


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst's (LPA) Shikya Belfield and Lisa Schlembach made an unannounced inspection to the above facility on 5/31/2022 at 5: PM. The purpose for this inspection is to conduct a case management. LPA's Belfield and Schlembach met with Direct care Nai Saelee who assisted with the visit. Based on confidential interviews and a review of the licensing information system, it was confirmed that S1 ( see lic 811 dated 5/31/22) has continued to work in the facility with clients and has not been criminally record cleared to work in the facility with clients. Facility is being cited for violation of the Short Term Residential Therapeutic Program, Interim Licensing Standards (ILS), Version 4, Section 80019(e)(1): Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. Based on a confidential interview conducted, it was confirmed that the facility failed to meet the requirement of having a Facility manager on site. Facility is being cited for violation of the Short Term Residential Therapeutic Program, Interim Licensing Standards (ILS), Version 4, Section 87065(f) Personnel Requirements. The licensee shall designate at least one facility manager to be present at all times when one or more children are present. Facility is being cited for violation of the Short Term Residential Therapeutic Program, Interim Licensing Standards (ILS), Version 4, Sections 80019(e)(1): Criminal Record Clearance and Section 87065(f) Personnel Requirements. An exit interview was conducted and copy of this report along with appeal rights will be sent to administrator Khea Gumbs.

met_with: Nai Saelee


summary: Facility Evaluation - 1 deficiency

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Narrative:
On 6-12-24 12:15PM, Licensing Program Analyst (LPA) George Karkazis conducted an unannounced inspection at REFUGE 3, and met with Dwayne White, Administrator, who helped with the inspection. The facility was clean and in good repair, clients and staff interacting peacefully. The purpose of the inspection was to follow up on complaint investigation for REFUGE 3, dated 3-29-24 #14CR-20240329140947. During the course of the investigation, three clients were on AWOL 3-28-24. LPA conducted document research in LPA email and the San Bruno Incident Report Inbox. As of 6-3-24, there is still no incident report for the AWOL incident dated 3-28-24. The facility is being cited for Title 22, Division 6, Chapter 1, Article 6 80061(b) Reporting Requirements. An exit interview was conducted, appeal rights provided, and a copy of was given to Dwayne White Administrator.

Deficiencies:
80061(b): 1
2
3
4
5
6
7Facility shall send the incident report for the three clients who AWOLed 3-28-24.

title:
1
2
3
4
5
6
780061(b) Reporting Requirements-Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours.  In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.

This requirement was not met as evidenced by


summary: Facility Evaluation - 1 deficiency

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Narrative:
On 9/17/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit at the faciilty in order to deliver notice of deficiencies observed during an investigation at the facility. LPA met with Administrator Brittany Flentroy and Facility Manager Sara Haile and informed of the purpose of the visit. During an investigation at the facility, LPA observed that the facility submitted an incident report for a restraint that took place on 4/11/24. The report indicated staff "contained" a resident, and through this investigation, LPA learned that this "containment" was a restraint. The reporting requirements for restraints were not followed, due to the report not indicating the type of restraint used nor the length of the restraint. Further, the facility's plan of operation indicates that no restraints will be performed at any time. Additionally, LPA observed that staff statements reflect that the facility has blanket policies to conduct searches of residents at intake and to confiscate cell phones. LPA observed that the facility's plan of operation indicates that residents will be allowed to access their cellphones and that no specific search policies at intake are outlined in the plan of operation. LPA is issuing a citation of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section Reporting Requirements, Subsection (i)(7)(C) and ILS Section Plan of Operation, Subsection (f). LPA also verbally advised of ILS Personal Rights to provide technical support and ensure familiarity with relevant regulations for the plan of operation updates. An exit interview was conducted, plans of correction (POCs) were developed, and a copy of this report and of the licensee's appeal rights were left with Administrator Brittany Flentroy, whose signature on this form confirms receipt.

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

met_with: Administrator Brittany Flentroy, Facility Manager Sara Haile

title:
Reporting Requirements
(i)(7) Incident Reports documenting the use of manual restraints must include the following


summary: Facility Evaluation

raw_content:
Narrative:
On 9-27-24 10:55AM, Licensing Program Analyst (LPA) George Karkazis conducted an unannounced inspection at REFUGE 3, and met with Brittany Flentroy, Administrator, who helped with the inspection. During the course of investigating REFUGE III Complaint 8-16-24 #14-CR-20240816150249, LPA discovered that C1 went AWOL on 8-14-24 from 6:45PM to 11:45PM. The incident report was received on 8-26-24 in the San Bruno Incident Report Inbox, 12 days later. In addition, while interviewing C1's responsible representative, they stated that C1 was transferred from REFUGE 3 to REFUGE 2 without notification or an address. The facility is being issued a Technical Violation for Title 22, Division 6, Chapter 1, Article 6, Reporting Requirements 80061(b). The facility is being issued a citation for Interim Licensing Standards Removal and/or Transfer Procedures 87068.4(b)(1), Type B. An exit interview was conducted, appeal rights provided and a copy of this report was given to Brittany Flentroy, Administrator.

met_with: Brittany Flentroy, Administrator


raw_content:
Narrative:
Exit interview was conducted and a copy of this report along with appeal of rights was printed and left with Dwayne White, Administrator whose signature on this form confirms receipt of these documents.

Investigation Findings:
13On 01/21/26 at 10:40 am, Licensing Program Analyst (LPA) Simran Nayyar conducted a visit to the above agency to deliver findings on the allegation listed above. Upon arrival LPA Nayyar rang the bell and got no answer. LPA Nayyar then called Jason Henderson, Licensee and let him know she was there. Licensee let LPA Nayyar know the administrator will arrive shortly. At 11:15 am, LPA Nayyar met with Dwayne White, Administrator and Marla Anderson, Program Manager who assisted with the inspection. According to confidential interviews, record review, and observations conducted by the Investigations Brach, it was determined that the allegation "Staff did not prevent an individual in the facility from giving illegal drugs to youth", had inconsistent support. Although the allegation may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated, and no Title 22 deficiencies were observed. (Refer to continuation page on LIC 809-C). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Simran Nayyar LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., Suite San Bruno, CA Facility Name: R.E.F.U.G.E.III, THEFACILITY NUMBER: VISIT DATE: 01/21/2026

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


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Paul Simien made an unannounced visit to the above listed facility to inform them of the findings for the above listed allegations. LPA discussed this with Dwayne White, Administrator Superviser (AS) at 11: AM on 2/27/26. Based on confidential interviews conducted it was determined that the allegation listed above is Substantiated. Based on witnesses interviewed, it was determined that the facility refused to provide transportation for a client on12/25/26 and doesn't report incidents to client's social worker in a timely manner. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. As a result of this visit, two Interim Licensing Standards violation ( Transportation (c) and Reporting Requirements (b)(4)(A). The facility will be cited (see 809-Ds for details). Appeal rights were discussed and provided. Exit interview was conducted and a copy of this report was provided to AS. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Joel Segura LICENSING EVALUATOR NAME: Paul Simien 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 Citations on this Visit Report are Under Appeal! Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN JOSE RO, N. First Street, Ste. San Jose, CA Facility Name: R.E.F.U.G.E.III, THEFACILITY NUMBER: 015650058

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

met_with: Dwayne White, Administrator Superviser

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
On Friday, April 17th 2026, Licensing Program Analyst (LPA) Mariah Hawkins and Licensing Program Manager (LPM) Isabel Diego conducted a random annual inspection in order to meet the 2-year requirement. The facility's last annual/2-year inspection was conducted on April 19th 2024. LPA and LPM met with Administrator Dwayne White and Program Manager Marla Anderson and informed of the purpose of the visit. At 10:15AM, LPA and LPM conducted a tour of the facility site. LPA and LPM observed the facility to be clean and kitchen and bathrooms to be sanitary. Medications, chemicals, and sharps were stored in locked drawers, and medications were stored in separate bins for each client. Bedrooms had two individual beds with linens. Lights were observed to be functioning in all rooms. License, personal rights, and facility sketch are posted. At 10:18AM, LPA and LPM measured hot water at the sink in the client bathroom and observed hot water to measure 124. F. LPA and LPM issued a citation of California Code of Regulations (CCR), Title 22, Section 80088(e) Fixtures, Furniture, Equipment, and Supplies. See attached LIC 809-D. The water heater was turned down at visit. Water was retested at 4:58PM and measured 107. F. At 10:43AM, LPA and LPM observed a broken individual-sized trampoline and old removed plexi-glass and doors in the backyard, which LPA and LPM advised be removed. At 10:51AM, LPA and LPM observed that one of the front wooden steps was unstable and dipped down when stepped on. LPA and LPM issued a citation of CCR, Title 22, Section 80087(a) Buildings and Grounds. See attached LIC 809-D. Continued / See Page PAGE At 10:52AM, LPA and LPM observed that cameras were posted in the living room, dining room, back utility room, outside by the front door, and two in the backyard. LPA and LPM and Administrator discussed PIN 24-09-CRP on surveillance cameras and the requirement to add camera policies to the plan of operation/program statement. LPA and LPM issued a citation of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), Version 5 (V5), Section 87022(a) Plan of Operation. See attached LIC 809-D. At 11AM, LPA and LPM reviewed client records for the four clients in care. At 12:35PM, LPA and LPM discussed the requirement to provide locked containers to clients for their contraceptives, which present staff confirmed have not been provided to clients. LPA and LPM issued a citation of STRTP ILS V Section 87075(b)(1)(A) Health Related Services. See attached LIC 809-D. At 2:13PM, LPA and LPM observed multiple discrepancies in the clients' medication records. LPA and LPM observed that C1's (See LIC Confidential Names) medication bin contained one medication bottle with a label that does not have dose instructions and one medication bottle with handwritten instructions that differ from the original instructions printed on the label. C1's LIC Centrally Stored Medication and Destruction Record was incomplete and missing the prescribing physician, issuing pharmacy, date administration was started, and medication expiration date. Additionally, C2's medication bin contained two medication bottles with handwritten labels that do not list the client name, prescription number, issuing pharmacy, date filled, or expiration date. C2's file contained a prescription order for five medications and three were not logged on the LIC 622 nor stored in the medication bin and are presently unaccounted for. Lastly, C3's file contained a LIC 622 that listed an incorrect drug strength description for one medication. LPA and LPM issued citations of CCR, Title 22, Section 80075(k)(2) and 80075(k)(4) Health Related Services. See attached LIC 809-D. At 4PM, LPA and LPM observed that 4 of 4 client files were missing documentation of the interagency placement committee's written determination and the qualified individual's assessment of the child, required to be completed and provided to the STRTP. LPA and LPM issued a citation of STRTP ILS V5, Section 87070(b)(8)(A) Children's Records. See attached LIC 809-D. Continued / See Page PAGE At 4PM, LPA and LPM observed that 4 of 4 client files were missing admission agreements. LPA and LPM issued a citation of CCR, Title 22, Section 80068(g) Admission Agreements. See attached LIC 809-D. At 4PM, LPA and LPM observed that 4 of 4 client files were missing documentation of allowance distribution and the allowance binder had no documentation of distribution of allowance in 2026. LPA and LPM issued citations of 87077(a)(2) Personal Services and 87072(c)(36) Personal Rights. See attached LIC 809-D. During visit, LPA and LPM observed that there was nalaxone stored in the facility. LPA, LPM, and Administrator discussed PIN 25-01-CRP and PIN 23-11-CRP. LPA and LPM requested that a waiver be submitted per PIN 23-11-CRP for the administration of nalaxone by June 1st 2026. During visit, LPA, LPM, and Administrator discussed the program model. Administrator stated that the program is working with the local county to provide a tailored program for the county's needs. Based on this discussion, LPA advised that the program statement may need to be updated to reflect the program changes. LPA requested that a copy of the contract with the county be provided to LPA by Monday, April 20th 2026. A continuation visit will be conducted in order to complete the personnel record review and interview portions of the inspection. An exit interview was conducted, and a copy of this report, the attached LIC 809-D pages, the LIC Confidential Names, and the licensee's appeal rights were provided to Administrator.

met_with: Administrator Dwayne White; Program Manager Marla Anderson