summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On August 3, Licensing Program Analyst (LPA) was met by facility representative Will Hayes. The purpose for this inspection is to seek additional information and conduct interviews with the minors in care. LPA previously obtained copies of Needs and Services Plans, Admission agreements and client roster for the facility on August 2, 2023. LPA conducted interviews with three of the four minors in care. 1 minor was attending summer school during this inspection. Based on confidential interviews with staff and minors along with record review, there is a preponderance of the evidence to prove the above allegation is substantiated. The facility is being cited for a violation of Interim Licensing Standards STRTP, Title 22, Division 6, Section 87061(b-f) Reporting Requirements An exit interview was conducted with Will Hayes and a copy of this report, and appeal rights were provided. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Wayne Aoki 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 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SIERRA CASCADE AC/SC, E SHAW AVE FACILITY NAME: MICHIGAN HOUSE #2FACILITY NUMBER: 107202606

met_with: Will Hayes


state: CA

facility_name: MICHIGAN HOUSE #2

summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Sonia Sanchez traveled to Michigan House #2 located in Fresno, CA to conduct an unannounced complaint inpsectoin and met with Roc Green, Assistant House Manager. The purpose of the inspection was to deliver the findings for the above complaint allegation. Based on interviews it was determined that staff spoke inappropriately to minor. Based on the LPA's confidential interviews and records review which were conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be substantiated. A deficiency is being cited for the Interim Licensing Standards (ILS) Chapter 8.8, Articles 6, Section 87072(c)(1) Personal Rights. A copy of the report and Appeal Rights were discussed and provided to Roc Green, Assistant House Manager at the STRTP. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Sonia Sanchez 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 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE FACILITY NAME: MICHIGAN HOUSE #2FACILITY NUMBER: 107202606

report_type: Complaint Investigation

met_with: Roc Green

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
On this date, March 24, 2022 at 09: AM, an unannounced required annual inspection was conducted by Licensing Program Analyst (LPA) Wayne Aoki. LPA was met by Assistant House Manager, Monique Cannon . LPA inspected the facility, inside and out. Centrally stored medications and sharps are maintained in a locked file cabinet. LPA inspected the medications for the minors in care. The facility has a written emergency disaster plan. All facility smoke and carbon monoxide detectors were tested and appear to be in appropriate working order, fire extinguisher is properly charged and was last serviced July 7, 2021. Individual beds were observed with appropriate clean linens and are in good repair. There is at least one week supply of nonperishable and a two day supply of perishable foods. The facility is maintained at 70 degrees. Hot water temperature measured 112 degrees. Facility cameras are allowed in the facility and there are no pets. There are no firearms in the facility and no bodies of water. There were 3 staff present during this inspection. Both staff and minor's files reviewed. Interviews with staff and minors in placement were conducted .LPA interviewed 3 staff and 2 minors during the inspection. LPA reviewed the facility's disaster plan, sampled medication and reviewed facility logs. LPAs requested the following updated documents be sent to LPA, D. Boyd by March 31, 2022. LIC 308, LIC 309, LIC 400, LIC 500 and LIC 610C There were no deficiencies cited during this inspection. A copy of this report was left at the facility at the conclusion of the inspection

report_type: Facility Evaluation

visit_type: Annual

met_with: Monique Cannon


summary: Facility Evaluation

raw_content:
Narrative:
On 07/22/2022, an unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian at 8:45AM. During the inspection, LPA met with Administrator Sena Streets, House Manager Will Haynes and staff member Monique Cannon and inspected the facility inside and out. LPA reviewed two children's records and reviewed two staff personnel records for the facility. LPA interviewed two staff at 10: AM. LPA interviewed two children at 10:20AM. A medication review was conducted at 10:45AM. LPA conducted exit interview with Sena Streets, Administrator at 11: PM. A copy of this report was given to Sena Streets, Administrator on this date.

visit_type: Case Management

met_with: Sena Streets, Will Haynes, Monique Cannon


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Jessica Rodriguez on July 24, 2023, at 9: A.M. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9(a)(2). During the inspection, LPA Rodriguez met with Assistant Manager, Monique Cannon and inspected the facility inside and out. LPA reviewed 4 of 4 child's records and 2 of 2 staff personnel files on site at the facility. LPA reviewed 4 of 4 child's psychotropic medications and medication records. LPA interviewed 2 of 2 staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 3 of 4 children currently prescribed psychotropic medication. LPA will interview the last child at another time, due to not being at the facility. No deficiencies are being cited at this time. LPA conducted exit interview with Assistant Manager, Monique Cannon. LPA provided a copy of this licensing report to Assistant Manager.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, An unannounced annual inspection was conducted by Licensing Program Analysts (LPAs), Lidia Tinoco and Miriam Flores at the Michigan House STRTP in Fresno, CA. LPAs met with Administrator, Sena Streets. A physical plant inspection was conducted and included the following checks. Facility grounds are clean and free of debris. Adequate indoor and outdoor activity space and materials observed. The facility is maintained at 72 degrees. All facility smoke detectors and carbon monoxide detectors are in appropriate working order. Facility maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. 3 clients require medications currently, facility has the ability to keep Medications locked and centrally stored. Individual beds were observed with appropriate clean linens and are in good repair. LPA discussed with Administrator the Program Statement and Plan of Operation updates to reflect the most updated regulations. The program currently has a due date of June 28, 2024. If more time is needed, Administrator will notify assigned LPA prior to the due date. Licensee has obtained Mental Health Certification Including the following: Mental Health Program Approval is valid from September 18, 2023 through September 17, 2024. Licensee has obtained National Accreditation through CARF valid through August 31, 2025. No firearms or weapons are allowed in the facility. Facility appears to be meeting the terms and conditions of their license. LPA reviewed 4 client files and 5 staff files. LPA conducted three client interviews and two staff interviews. One Type B deficiency was cited (See LIC809D) and two Technical Assistance (See LIC9102) were issued on this date. A copy of this report was provided along with appeal rights at the conclusion of the inspection.

met_with: Sena Streets


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPAs) Reyna Martinez and Briana Placencia on July 3, 2024 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPAs met with Sena Streets, Administrator and inspected the facility inside and out. LPAs reviewed 1 child record and 2 staff personnel files on site at the facility. LPAs reviewed 1 child psychotropic medications and medication records. LPAs interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPAs were unable to interview 1 child currently on psychotropic medication due to child at school. LPAs will attempt to interview 1 child at a later time. LPAs provided a copy of the licensing report to Sena Streets, Administrator. No deficiencies are being cited at this time. LPAs conducted exit interview with Sena Streets, Administrator.


summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Sonia Sanchez conducted a complaint inspection and met with Shardae Thomas, Direct Care Staff. The purpose of the inspection was to deliver the findings for the above complaint allegations. The Department has investigated the complaint alleging lack of client supervision, staff allowing clients to vape in the home, client was required to receive a haircut, and facility does not include all clients in planned activities. LPA conducted interviews and obtained documentation. There were inconsistencies in the confidential interviews. Although the allegations may have happened or is valid, there is not a preponderance of evidence to provide the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report and appeal rights were discussed and provided to Shardae at the end of the visit. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Vanessa Galvan LICENSING EVALUATOR NAME: Sonia Sanchez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Shardae Thomas

complaint_status: unsubstantiated


facility_name: MILE HIGH LEGEND HOME

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced complaint investigation inspection at the facility and met with staff Beverly Knox (S1) who assisted with the inspection. The Department's Investigations Branch Investigator, Blake Williams (IB), investigated this complaint by conducting confidential interviews with the Administrator, County Social Worker, three staff, and five children on 8/30/2021, 9/23/2021, 9/24/2021, 9/28/2021, and 10/6/2021. IB found that a child involved has a history of making up accusations when he does not get his way, and the child was unable or unwilling to give any details about the allegation. The accused staff denied the allegation, and other children interviewed also denied the allegation occurred. Based on all interviews IB found that there was not a preponderance of the evidence to prove that the allegation did or did not occur, therefore the allegation is found to be Unsubstantiated. An exit interview was conducted with S1 and a copy of this report along with appeal rights was emailed to her with a read receipt which will serve as the record of receipt. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Alyssa M Burgess LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

met_with: Beverly Knox, Steve Dogan


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
During the investigation, LPA Baca investigated the complaint Minor was sexually abused by another minor while in care. Interviews with Admin, Staff 1, Staff 3, Director, FY1 and Administrator stated that when staff were called downstairs for a crisis with another youth in the house, in where Staff1 no longer had an eyesight on the upstairs hallway, FY3 took advantage of the situation and went into FY1 and FY2 bedroom, sat on the bed and rubbed FY1 leg and himself while getting an erection and the tip of his penis was briefly seen by FY1, FY1 asked FY3 to leave and FY3 left. After several days FY1 and FY2 told staff about the incident while at an outing, and FY3 was moved to the other facility the same day in Fairfield until his probation officer picked him up. Interview with FY3 stated that nothing happened in the room and refused to talk to LPA about anything Interview with probation officer stated that she believed the incident happened, however does not believe it was to harm FY1. This allegation has been found to be UNSUBSTANTIATED meaning that allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

Investigation Findings:
13Licensing Program analyst (LPA) Jennifer Baca arrived at the agency to conduct an unannounced complaint inspection on 9.22.2022 at 10:00Am. LPA Baca spoke with Steve Dogan , Administrator to discuss the findings of the complaint investigation and allegation stated above. LPA informed agency staff this case was investigated by LPA Baca. The initial 10-day complaint investigation inspection was conducted at the agency on 8.9.2022, by LPA Johnson Documents received for staff included the following: Staff roster, Staff phone numbers and Staff schedule. Documents regarding foster Youth included the following: Needs and services. Interviews were conducted with Director 9.7.2022, Staff 1 on 9.9.2022, Administrator 9.9.2022, Staff 2 on 9.9.2022, Staff 3 on 9.12.2022, FY1 on 8.9.2022, FY3 on 9.21.2022, Probation officer on 9.13. LPA was unable to interview Reporting party after multiple attempts of contacting and leaving a return number. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Jennifer Baca LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MILE HIGH LEGEND HOMEFACILITY NUMBER: VISIT DATE: 09/21/2022

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

met_with: Steve Dogan, Administrator


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Both the client and staff denied that there was any romantic relationship between them. On 2/6/2023, C1 left the facility without permission and ED followed the client to an apartment. ED knocked on the door and S1 answered the door. ED told S1 to have C1 come out, however S1 lied and denied that C1 was there. In S1's interview she informed IB this was because she wanted to help C1. ED stated he would call Law Enforcement if C1 did not come out and C1 did come out. S1 was immediately terminated. Interviews with one client revealed that S1 and C1 would often be together in areas of the facility which cameras do not reach, and which are restricted to staff-only, such as the medication room and the laundry room. One staff interviewed stated that S1 did spend time in the laundry room to take breaks. Also revealed in the client's interview was that C1 would make inappropriate gestures about S1, such as a, "butt-smacking," gesture, and described S1 and C1's relationship as, "weird." There were no disclosures from anyone interviewed that there was a sexual or romantic relationship between S1 and C1. Based on IBs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Health and Safety Code Section 1558(a)(2) is being cited on the attached LIC 9099D. An exit interview was conducted with FM and a copy of this report and appeal rights was left with him.

Investigation Findings:
13Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced complaint investigation inspection at the facility and met with Facility Manager (FM) Steven Anderson, who assisted with the inspection. CCL's Investigations Branch Investigator (IB) Jeff LaGrange investigated this complaint by reviewing personnel records, complaint history, and a police incident report, and by conducting confidential interviews with the Executive Director, Administrator of another facility, three staff, and four clients on 2/15/2023, 4/14/2023, and 4/17/2023. Based on these reviews and interviews, IB found that on 2/6/2023, one client was found in the personal residence of staff (S1, see Confidential Names List dated 5/10/2023). Executive Director, the involved staff, and the involved client (C1) confirmed this to be true. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Alyssa M Burgess LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MILE HIGH LEGEND HOMEFACILITY NUMBER: VISIT DATE: 05/10/2023

met_with: Steven Anderson


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
It was confirmed during a conversation with the Administrator on 4/18/2023, that the electricity to the house was turned off by staff around 10: PM, one night. The reason giving was "the kids should have been in bed at that time and weren't'. C1 also disclosed during a confidential interview that the electricity to the whole house had been turned off. A client interviewed during an Annual Inspection, disclosed the same when asked about the electricity being turned off. There was also a video sent by C1's Case Manger confirming the electricity was turned off as well. It was also confirmed by clients and staff that the electricity to the outlet plugs in the kitchen are turned off. This is to prevent clients from charging their cell phones. Clients sign a contract that they will not have a personal cell phone until they reach a certain level. This is not in the Program Statement or addressed in their Needs and Service Plans. However, C1's cell phone was not taken by staff and remained in C1's possession. There is a phone in the house, that all clients can use to call social worker, lawyers and for their own personal use. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1 80072(a)(2), are being cited on the attached LIC 9099D." An exit interview was conducted on 5/10/2023, the report/appeal process were reviewed with the Manager. A copy of this report/appeal rights were emailed to the Administrator, Steve Dogan due to technical difficulties.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton arrived at the home to delivery findings on a unannounced complaint investigation on 5/10/2023. LPA Mary Shelton spoke with the Manager, to discuss the findings of the complaint investigation and allegation stated above. The initial 10-day complaint investigation inspection was conducted by LPA Mary Shelton at the facility on 3/7/2023. Copies of facility documentation were provided to LPA that included: Rules Package, Personal Rights, Facility Policies, Bedtime Rules, House Policy, Visitation Rules & Policy, Phone Policy, Sign Out Procedure, School Attendance Policy, Level System, Discipline Policies, Children's Complaint/Grievance Procedures, Theft and Loss Policy, Contraband Search Policy, Register of Facility Clients/Residents, Personnel Report, Client's Needs and Service Plan, Behavioral Health Needs & Service Plan, staff training records, Case Notes and Incident Reports. Interviews were conducted with clients, social workers, Behavior Specialists, Direct Care Staff, Administrator and both the Executive Director and Program Director between 3/7/2023 and 4/28/2023. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Mary Shelton LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MILE HIGH LEGEND HOMEFACILITY NUMBER: VISIT DATE: 05/10/2023

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

met_with: Manager, Steven Anderson


raw_content:
Narrative:
Allegation: Staff locked minors out of facility for an extended period of time. It was determined during the investigation that C1 was not locked out of the house for an extended period. The incident was discussed in C1's latest, CFT Meeting. The County Supervising Social Worker stated the incident was embellished and C1 was not locked outside. This discussion occurred in the presence of C1. The Supervising Social Worker was present during the meeting and stated that she talked to C1 outside the home and stated C1 could of went back in the home as well. C1 felt he was locked out due to staff wanted C1 to turn in C1's cell phone. However, C1 did keep his phone and came inside the home after returning from an AWOL. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff did not provide food and water to minor. It was determined during confidential interviews with Direct Care Staff and Behavioral Specialist staff that C1 was offered food/water when C1 was outside the home. The County Supervising Social Worker was on the phone when C1 was ordering food from Panera Bread. C1 choose to leave the home and get food from Panera Bread. All clients interviewed stated there was food in the home and available when they wanted to eat. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff did not allow minor to use bathroom. It was determined during interviews with clients and staff that C1 could have entered the home to use the bathroom. Staff and clients stated during interviews they could use the restroom whenever they wanted. During C1's interview he never stated C1 could not use the bathroom while outside. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No title 22 regulations were cited during today's inspection. An exit interview was conducted on 5/10/2023, the report/appeal process were reviewed with the Manager. A copy of this report/appeal rights were emailed to the Administrator, Steve Dogan due to technical difficulties.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton arrived at the home to delivery findings on an unannounced complaint investigation on 5/10/2023. LPA Mary Shelton spoke with the Manager, to discuss the findings of the complaint investigation and allegation stated above. The initial 10-day complaint investigation inspection was conducted by LPA Mary Shelton at the facility on 3/7/2023. Copies of facility documentation were provided to LPA that included: Rules Package, Personal Rights, Facility Policies, Bedtime Rules, House Policy, Visitation Rules & Policy, Phone Policy, Sign Out Procedure, School Attendance Policy, Level System, Discipline Policies, Children's Complaint/Grievance Procedures, Theft and Loss Policy, Contraband Search Policy, Register of Facility Clients/Residents, Personnel Report, Client's Needs and Service Plan, Behavioral Health Needs & Service Plan, staff training records, Case Notes and Incident Reports. Interviews were conducted with clients, social workers, Behavior Specialists, Direct Care Staff, Administrator and both the Executive Director and Program Director between 3/7/2023 and 4/28/2023. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Mary Shelton LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: MILE HIGH LEGEND HOMEFACILITY NUMBER: VISIT DATE: 05/10/2023

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


raw_content:
Narrative:
Interviews with all staff members, FM, S1, S5, and S6, stated that the only time a staff member stays the night at the facility, is if they are working an overnight shift. Additionally, when asking the youth (C1, C2, C3, and C4) if they had ever seen a staff member do drugs at the facility, they all stated, no, never. This Department has investigated the complaint alleging that staff engaged in drug activity in the home posing a risk to minors in care. We have found that the complaint is Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with the Jose Reyes. A copy of this report, and appeal rights were given.

Investigation Findings:
13On Wednesday, January 15th, 2024 at 12PM, Licensing Program Analyst (LPA) Brittany Crass, made an unannounced complaint investigation inspection at the facility, to deliver findings for the allegation listed above. LPA met with the Residential Counselor, Jose Reyes, who assisted with the inspection. LPA conducted the initial-10 day complaint investigation at the Facility on 12/10/2024. Between 12/10/24 and 1/6/25, LPA interviewed four youth (C1, C2, C3, and C4), four staff members (FM, S1, S5, and S6), and the Administrator (S4). LPA was unable to get ahold of the Reporting Party. It was alleged that a staff member had been using the facility as their personal living space and doing drugs at the facility. During confidential interviews, both youth and staff appeared to be surprised by this allegation, and all denied it occurring. (continued on LIC 9099-C). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Brittany Crass LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MILE HIGH LEGEND HOMEFACILITY NUMBER: VISIT DATE: 01/15/2025

met_with: Jose Reyes


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced post-licensing inspection at the facility and met with Administrator Steve Dogan, who assisted with the inspection. LPA utilized the CARE Tool for this inspection. LPA and Administrator conducted a walk-through of the facility. LPA observed three client bedrooms, one staff office, three full bathrooms, a kitchen, garage, backyard, living room, laundry room, and dining room. LPA observed the facility to be safe, clean, and sanitary. All bedrooms, bathrooms, and kitchen were equipped with all necessary items, which were in good repair. Water temperature in the clients' bathroom measured at 108.8 degrees Fahrenheit, which is within the required range. LPA observed no deficiencies during the walk-through. LPA reviewed the facility's operations. LPA found during the post-licensing inspection at the Licensee's other facility, that the length of time for each hold was not clear in the descriptions as well as there was not a clear licensee post-restraint evaluation. A Technical Violation advisory note was issued for this. LPA completed the Physical Plant, Operations, Core Services and Supports, and Disaster Preparedness domains from the CARE Tool, and no other deficiencies were found. LPA was unable to complete this inspection on this date and will return on another date to do so to complete the staff and client file reviews. An exit interview was conducted with Administrator and a copy of this report will be emailed to him with a read receipt, which will serve as his confirmation for receiving the document.

met_with: Steve Dogan


summary: Facility Evaluation

raw_content:
Narrative:
On 8/10/2021, Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced post-licensing inspection at the facility and met with Administrator Steve Dogan, who assisted with the inspection. LPA utilized the CARE Tool for this inspection. LPA and Administrator conducted a walk-through of the facility. LPA observed three client bedrooms, one staff office, three full bathrooms, a kitchen, garage, backyard, living room, laundry room, and dining room. LPA observed the facility to be safe, clean, and sanitary. All bedrooms, bathrooms, and kitchen were equipped with all necessary items, which were in good repair. Water temperature in the clients' bathroom measured at 108.8 degrees Fahrenheit, which is within the required range. LPA observed no deficiencies during the walk-through. LPA reviewed the facility's operations. LPA found during the post-licensing inspection at the Licensee's other facility, that the length of time for each hold was not clear in the descriptions as well as there was not a clear licensee post-restraint evaluation. A Technical Violation advisory note was issued for this. LPA completed the Physical Plant, Operations, Core Services and Supports, and Disaster Preparedness domains from the CARE Tool, and no other deficiencies were found. LPA was unable to complete this inspection on this date and returned on 8/11/2021 to complete the staff and client file reviews. On 8/11/2021, LPA completed the remaining domains in the CARE tool: Staffing and Client Records, and reviewed four client files and three staff files. LPA found that all client and staff files were in compliance, except for the following deficiency areas: Technical Violations (No Citation): 1. S1's Health Screening was not filled out by the physician. 2. C1 has not had a TB test in the five months that C1 has been placed, however, an appointment to do so is already scheduled. 3. C2 and C3 had no mention of money-handling capability in their Needs and Services Plans. 4. Client room sharing compatibility assessments were not completed. 5. C1's visitation information has not been completed. 6. There is no expiration date for medication on the Medication Administration Records, however, it is on the actual medication bottles. Citation - Type B: 1. S2 had 25 hours of verifiable annual training, which is under the required amount of 40 hours annually. Note: these Technical Violation Advisory Notes and B Citation were already issued during the post-licensing inspection. An exit interview was conducted with Administrator and a copy of this report will be emailed to him with a read receipt which will serve as the record of receipt for the documents.


facility_name: MILE HIGH MOUNTAIN TOP

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Investigation Findings:
13Licensing Program analyst (LPA) Jennifer Baca arrived at the agency to conduct an unannounced complaint inspection on 9.93.2022 at 10: Am. LPA Baca spoke with Steve Dogan , Administrator to discuss the findings of the complaint investigation and allegation stated above. LPA informed agency staff this case was investigated by LPA Baca. The initial 10-day complaint investigation inspection was conducted at the agency on 3.22.2022, by LPA Burgess. Documents received for staff included the following: Staff roster, Staff phone numbers and Staff schedule. Documents regarding foster Youth included the following: Medical records and school information. Interviews were conducted with Administrator 9.2.2022, Staff 1 on 9.02.2022, Director on 9.7.2022, FY1 on 9.8. LPA was unable to interview Reporting party or the Police officer after multiple attempts of contacting and leaving a return number. During the investigation, LPA Baca investigated the complaint staff did not prevent minors from engaging in inappropriate behavior. Interview with Admin and Staff 1 stated that the two youths that were accused of injuring FY1 had been awol at the time of the incident, and there was no youth at the facility at the time of the incident. Interview with Director stated that after an internal investigation he found that FY1 was the only youth at the facility at the time he AWOLed from the facility. Interview with FY1 stated that he refused to talk to LPA because the incident happened so long ago.As a result of the investigation and interviews conducted, the allegation staff did not prevent minors from engaging in inappropriate behavior. This allegation has been found to be UNSUBSTANTIATED meaning that allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Jennifer Baca 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:


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Narrative:
There were also multiple incidents in which one client was sexually inappropriate with another client by flirting, trying to show their genitals, dry-humping, and more. Interviews revealed that for the majority of the time, staff did intervene to stop this from occurring, however some clients stated that it was not at all times. One staff stated these incidents sometimes occurred quickly and out of view of staff. Clients stated they would often rough-house with each other, and some stated staff would tell them to stop. In one incident, a client allegedly poked another client in the anus. When staff became aware of the allegation, it was immediately reported and investigated by the facility. After the facility investigated, they issued a discharge notice for the client on an emergency basis to keep the other clients safe. Based on interviews LPA found there was a clear pattern of one client being physically inappropriate and aggressive with other clients in the home, and while action was taken with the aggressing client it is unclear if action could and should have been taken sooner, based on the information provided. During interviews with seven clients, six staff, the Clinician, the Administrator, and the Executive Director, LPA was informed that the house is clean. Clients have chores and do them daily. If a client does not do their chore, staff clean up after the clients or incentivize other clients to cover the chore for more points. Additionally, all individuals interviewed except for one stated that a mess does not last more than a day, and most of them stated it lasts less than hours. One client stated it might last up to a day and a half. One client stated that after a client was in the bathroom sometimes there would be pubic hair, feces, urine, and soap. One staff stated the floors are sticky sometimes. LPA has visited the facility unannounced on many occasions over years, and has not observed the home to be messy or dirty. (continued)... During interviews with clients, staff, a witness, Administrator, and the Executive Director, LPA learned that a client had their money stolen on at least one occasion, but possibly more than once. The client stated the money was locked up with staff and it went missing. Other clients stated another client stole the money, or that they heard that it was a staff. The Administrator stated it was looked into and it was unclear, as sometimes the client kept their belongings in their room instead of locking it up, as well as brought money in without telling staff how much there was. The Executive Director was unsure of the outcome and thought that management had figured it out, as well as stated that if the money was lost by staff, then it would be replaced. All clients stated they are allowed to lock their personal belongings up with staff for safe-keeping, and some choose to do so. Staff repeatedly encouraged the client to safeguard their money. One staff stated they brought up the missing money during management meetings, and it was brushed off. Additionally, in LPA's review of the client's allowance sheets, there were some errors and entries that were unclear. LPA brought this to the attention of the ED, who discussed this with Administrator. In another visit to the facility for an annual on 3/6/2024, LPA observed a random sample of a client's allowance sheet in which LPA again observed errors. LPA addressed this with the Administrator during that inspection. Based on conflicting information, and lack of information, it is unclear if in this instance the facility failed to safe-guard the client's money. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with FM and a copy of this report and appeal rights were provided to him.

Investigation Findings:
13Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced complaint investigation inspection at the facility and met with Facility Manager Steven Anderson, who assisted with the inspection. LPA investigated this complaint by reviewing client allowance records and conducting interviews with seven clients, six staff, a witness, the Administrator, the Clinician, and the Executive Director on 12/29/2023, 1/24/2024, 4/5/2024, 4/9/2024, 4/15/2024, 4/16/2024, 4/17/2024, 4/19/2024, and 4/22/2024. During interviews with clients, staff, a witness, Administrator, and the Executive Director, LPA learned of various incidents involving the clients which were inappropriate in nature. In one incident, two clients were fighting which resulted in one client being bitten by the other one, and going to the hospital. LPA was informed of mixed details during interviews. A witness stated the staff on shift responded immediately and appropriately to the fight. One client stated it took about five minutes for staff to respond. Another client stated when one client assaulted the staff, the staff left the situation, however the staff denied this. All interviews stated staff intervened and separated the clients. After this incident, the client was given a room change to keep the other client safe. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Alyssa M Burgess LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MILE HIGH MOUNTAIN TOPFACILITY NUMBER: VISIT DATE: 05/06/2024


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Narrative:
During interviews, one staff stated that due to the facility's consequences/level structure, it does not meet the clients' mental health needs as a therapeutic environment. One client felt the facility gives, "shitty," therapy, however they met with the therapist twice a week. The client refused to see the facility psychiatrist, and saw their Kaiser psychiatrist instead. LPA was informed by the Clinician and one client that this client sometimes refused to engage or participate in the mental health services offered to them by Mile High. Another client stated they did get therapy at the facility, but stated it was not all that they needed. When asked what else they needed, the client stated they did not know and it was only something, "someone," told them. One client stated there are Behavioral Techs at the facility but all they want to do is take them to the library and not talk to them, but the client also stated they refused to meet with mental health staff to have their mental health needs met, so it is unclear if they actually did not meet the client's needs. During other interviews with all other clients, they confirmed their mental health needs are met. There are Behavioral Techs who are in the facility daily to meet with the clients about their mental health and clients meet with the Clinician at least twice a week. Additionally, LPA was informed by the Clinician that a psychiatric nurse practitioner comes to the facility to assess the clients' medications and make recommendations. The facility has a psychiatrist as well who diagnoses clients and prescribes them medications. Based on LPAs interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. On this date the facility is being cited for a violation of the Short Term Residential Therapeutic Program Interim Licensing Standards, Version 5, Section 87089.1(a). An exit interview was conducted with FM and a copy of this report and appeal rights were provided to him. In an interview with another client, they stated that Admin has a, "slick mouth." When asked why they feel that way, they said because Admin told them, "if you keep acting up you're not going to get your full allowance," and, "always yelled." LPA clarified the meaning of yelling with the client, who maintained that Admin yelled, however gave no description of yelling. In another client interview, LPA was informed that Admin, "yells all the time." The client stated Admin yelled at a client to get out of another client's room. When clarification questions were asked, the client determined Admin was not yelling, only raising his voice. The other clients stated Admin does not yell at them. Staff informed LPA that Admin is the one to address consequences with the clients. The Program Director explained that because of this he gets a, "bad rep," but he is not yelling. LPA was informed that Admin has a, "stronger," voice and some clients will say he is yelling, "but he is just being firm." All staff interviewed denied that Admin yells at the clients. LPA was informed by one client that Executive Director (ED) Tegre Miles has cussed at them, telling them, "you're on bullshit." Another client stated ED yells at the clients, but it is only to get his point across and not to scare them. The other clients denied ED yells at them. LPA learned from the Program Director that ED is also the one to address the clients' behavior and consequences with them. LPA was informed that it is true that ED could have a softer approach with some of the more, "sensitive," clients, and they, "could see how some kids can perceive some things negatively, though it is never inappropriate." LPA was informed that ED will explain to clients the consequences of their actions and they won't like it. One staff stated that ED speaks to the clients, "very bold, disrespectful, and yelling and cursing." When asked for an example of this, the staff stated ED says, "I don't give a shit," "I don't give a damn." The staff stated however, that it is nothing abusive. Another staff stated ED has said to clients before to, "cut this bullshit out." When asked about cussing to the clients, ED stated that he sometimes does talk to the clients in their language, or paraphrases what they say to him. ED stated he does not yell at the clients, but is a straight-talker with them. Based on this information it is not clear if ED and Admin do yell at the clients, or if it is a perception by the clients due to the nature of the conversations, the language used, and/or the natural voices of the ED and Admin. During interviews with seven clients, six staff, the Clinician, the Administrator, and the Executive Director, LPA was informed that the house is clean. Clients have chores and do them daily. If a client does not do their chore, staff clean up after the clients or incentivize other clients to cover the chore for more points. Additionally, all individuals interviewed except for one stated that a mess does not last more than a day, and most of them stated it lasts less than hours. One client stated it might last up to a day and a half. One client stated that after a client was in the bathroom sometimes there would be pubic hair, feces, urine, and soap. One staff stated the floors are sticky sometimes. LPA has visited the facility unannounced on many occasions over years, and has not observed the home to be messy or dirty. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. LPA is issuing an advisory note to address the language used by the Executive Director with the clients. An exit interview was conducted with __ and a copy of this report and appeal rights were provided to __.

Investigation Findings:
13Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced complaint investigation inspection at the facility and met with Facility Manager Steven Anderson, who assisted with the inspection. LPA investigated this complaint by reviewing CFT notes and conducting interviews with eight clients, six staff, a witness, the Administrator, the Program Director, the Clinician, and the Executive Director on 12/29/2023, 1/24/2024, 4/5/2024, 4/9/2024, 4/15/2024, 4/16/2024, 4/17/2024, 4/19/2024, and 4/22/2024. One of the clients had been experiencing an increase in mental health crises and adverse behaviors. An emergency Child & Family Team Meeting (CFT) was scheduled to address this. After the emergency CFT was held on 2/5/2024, LPA reviewed the notes and found that neither the client's safety, nor the client's mental health concerns were discussed in the CFT, for which the purpose of the meeting was. Instead, only school and placement plans were discussed. When LPA asked Admin and Program Director why this was, they were unsure. LPA instructed Admin and PD to ensure another CFT is called to address these areas of concern. Both agreed to this, and the meeting occurred on 2/13/2024 in which the client's mental health needs and safety planning were discussed. A safety plan was created and the client was moved to Mile High's other house to improve the client's mental health. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Alyssa M Burgess LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MILE HIGH MOUNTAIN TOPFACILITY NUMBER: VISIT DATE: 05/06/2024


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Narrative:
Review of the police reports revealed: LE arrived and observed ED and FM restraining C1 on the bed. C1 informed LE that ED pinched C1 during the restraint and twisted C1's arms, when he came in from the window. C1 also also reported ED was digging ED's elbow into C1's back. LE did later observe on C1, "fresh abrasions with bruising and redness to [C1's] left forearm, which is the side ED restrained C1 on," and where it was alleged that ED pinched C1. Interviews with the children revealed: one child stated they did not see the restraint but heard, "just a bunch of shouting and yelling." The child denied that any staff have hurt any child at the facility. One child stated ED and FM came into the room saying nothing and just restrained C1 on a dresser and then on a bed where C1 was on their stomach for a while until C1 stated they could not breathe. Then ED and FM flipped C1 over, and picked C1 and, "put [C1's] head against the wall." The child stated ED told LE that they were restraining C1 due to them spitting on ED and FM. C1 admitted to LPA they had been on the roof out of boredom, then went to another client's room waiting for the ED and FM to arrive. C1 explained that ED and FM pulled C1 off of the bed to restrain them by taking their arms up and putting them on the bed on their stomach, "to where I couldn't breathe." C1 explained then ED was, "talking crap," to them and pinching them on their arm, which left bruises. FM was not doing anything that was hurting C1. The restraint ended when the police arrived. Interviews with staff revealed: one staff did not witness the restraint as they were supervising the other clients. One staff stated it was when C1 kicked out at ED/FM that they initiated the restraint. The staff denied that anyone fell and that C1 was not put on their stomach. FM informed LPA that when he and ED arrived, they entered the room, asked the other client to leave and C1 was, "talking trash, doing threatening (gestures), so we went into the restraint." C1 was being threatening by, "looking like [C1] was going to swing at [ED]." Once on the bed, C1 was, "just sitting there, no struggle, just verbal threats," but they continued the restraint until LE arrived. FM confirmed they advanced on C1 in the room, and C1 was only making verbal threats. ED informed LPA he and FM attempted to verbally de-escalate C1 while C1 was sitting on a bed. C1 became upset and swung their fist out which is when the restraint was initiated, and they stood C1 up against a dresser. They moved to the bed and C1 was still making verbal threats until police arrived after about 15 to 20 minutes. LE arrived and took over. ED denied C1 was ever on their stomach, denied he was upset, and denied that he was hurting/pinching C1 during the restraint. FM and the staff denied FM or ED were rough with C1. FM admitted other things could have been tried before restraint. ED stated he could not evade because he did not have the space. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Admin, and a copy of this report and appeal rights were provided to you.

Investigation Findings:
13Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced complaint investigation inspection at the facility and met with Administrator Steve Dogan, who assisted with the inspection. LPA investigated this complaint by reviewing two police reports, the facility incident report, staff Emergency Intervention training records, and by conducting confidential interviews with three children, two staff, the Executive Director (ED), and the Facility Manager (FM), on 3/14/2024, 4/9/2024, 4/10/2024, 4/16/2024, 4/17/2024, and 5/6/2024. The facility incident report described the client (C1 - See Confidential Names List dated 7/10/2024) having been engaging in dangerous behavior of getting on the roof in the rain from their bedroom window, moving their bed into the hallway, trying to get into the attic, and throwing things at staff. ED and FM were called to assist. When ED/FM arrived, they saw C1 hanging outside of his window and entered the room. Then, C1 aggressively approached ED and FM, "within 3 feet," and had closed fists. That is when ED and FM placed C1 in a restraint. A struggle ensued and at one point they fell to the bed. ED and FM transitioned to a seated restraint with C1 on the bed and Law Enforcement (LE) was called. Once LE arrived, C1 was released from the hold and LE took over. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Alyssa M Burgess LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MILE HIGH MOUNTAIN TOPFACILITY NUMBER: VISIT DATE: 07/10/2024


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Narrative:
Interviews with staff and clients informed LPA that the client (C1 - See Confidential Names List dated 5/7/2025) struggled with substance use. Staff informed LPA that C1 would hallucinate during use. During one incident, staff informed LPA that they were following C1 when C AWOLd and appeared to be under the influence. C1 was trying to jump or pass through a fence and the staff tried to prevent C1 from doing so due to safety concerns. During this incident, C1's sweater got caught on the fence and tore. All clients informed LPA that staff have not handled clients in a rough manner. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Administrator and a copy of this report, Confidential Names List, and appeal rights were provided to him.

Investigation Findings:
13Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced complaint investigation inspection at the facility and met with Administrator Steven Anderson who assisted with the inspection. LPA investigated this complaint by reviewing incident reports, and by conducting confidential interviews with two clients, four staff, the Facility Manager, the Program Director, the Administrator, and the County Social Worker between 11/26/2024 and 4/29/2025. Despite making 11 attempts to speak with the client involved, LPA was unable to make contact with them. Confidential interviews with all facility personnel and all children informed LPA that staff have not made inappropriate comments towards clients, specifically calling a client a "pendejo." All clients informed LPA that staff do not speak inappriopriately to them. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Alyssa M Burgess LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: MILE HIGH MOUNTAIN TOPFACILITY NUMBER: VISIT DATE: 05/07/2025


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced post licensing inspection at the facility and met with Reyes Bonilla, Program Director (PD), and Tegre Miles, Executive Director (ED), who assisted with the inspection. LPA utilized the CARE Tool for this inspection. LPA and PD conducted a walk-through of the facility. LPA observed one deficiency: In the clients' bathroom, the water tap delivered water at 125.6 degrees, which is 5.6 degrees too high. LPA issued a Technical Violation advisory note for this. The water heater was turned down during this inspection. LPA completed the Physical Plant and Operations domains from the CARE Tool, and no other deficiencies were found. LPA was unable to complete this inspection on this date and will return on another date to do so. An exit interview was conducted with ED and PD and a copy of this report will be emailed to them with a read receipt, which will serve as their confirmation for receiving the document.

met_with: Reyes Bonilla


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced post licensing inspection at the facility and met with Reyes Bonilla, Program Director (PD), and Steve Dogan, Administrator, who assisted with the inspection. LPA utilized the CARE Tool for this inspection. LPA completed the rest of the domains in the CARE Tool, and found: two out of five clients reviewed had not had a recent TB test completed and five out of ten staff reviewed did not meet the 40 hour annual training requirement. LPA issued two type B citations for these deficiencies. LPA also found that the majority of all clients' Needs and Services Plans reviewed had either no signatures, or one or two signatures; there was a lack of visitation information in the files; there was not a complete manual restraint log, however there were incident reports with attached descriptions; the length of time for each hold was not clear in the descriptions; two staff did not have complete proof of education or verified experience in their files; the facility was utilizing "fines" to be repaid back from a portion of the client's allowance to a fund for activities; and room sharing compatibility assessments were not completed. LPA issues Technical Violation advisory notes for these issues. An exit interview was conducted with Administrator and PD and a copy of this report will be emailed to them with a read receipt, which will serve as their confirmation for receiving the documents.

met_with: Reyes Bonilla & Steve Dogan


summary: Facility Evaluation

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Narrative:
Licensing Program Analysts (LPA) Connie Goldie and Alyssa Burgess, made an unannounced required two-year annual inspection and met with Administrator, Steve Dogan who assisted with the inspection. LPAs and Facility Manager Jamilliah Cabunoc conducted a walk through of the facility and observed: three client bedrooms, one media room, one kitchen, on garage, the living room area, staff office, and backyard. The facility was clean and in good repair, aside from one client bedroom which had a boarded window from a client behavioral incident. Plans to repair the window are in effect. Also in that bedroom, there was a hole in the wall from a punch or kick. This is also planned to be repaired. LPAs learned that the facility had a minor issue with mice, however the facility already has been dealing with it and the pest control company treated the issue by servicing it today and will return in two weeks to treat it again. The water temperature measured at 111 degrees Fahrenheit which is within the required temperature range of 105 - 120 degrees Fahrenheit. LPAs observed an adequate amount of perishable and non-perishable foods. All bedrooms had adequate bedding and supplies. All lights were working. All poisons and disinfectants were locked and inaccessible. Medication was locked and inaccessible. Medication records showed that the Centrally Stored Medication and Destruction Records were out of date. All other regulations and requirements were met for medications. LPAs interviewed three clients. LPAs reviewed two client files. LPAs found that the two client files reviewed were missing items involving the Needs and Services Plans and other details required to be in the file. Due to not being able to finish the client file review on this date, these issues will be addressed in the annual continuation inspection. LPAs observed the facility's Board of Directors minutes, which have completed adequately and as required. LPAs observed a current fire clearance. An exit interview was conducted with Administrator Steve Dogan and a copy of this report was emailed to him with a read receipt which will serve as the record of receipt.


facility_name: MILESTONE GROUP HOME

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Narrative:
Confidential interviews revealed that staff conducted room checks and did not witness C1 and C2 engaging in any inappropriate behavior. However, when staff was made aware of the alleged allegation C1's room was changed, and staff were directed to increase supervision on both C1 and C2 to ensure proper supervision was carried out. Documents reviewed indicated that there was no indication that C2 needed extra supervision. Based on confidential interviews and documents reviewed during the investigation, the allegation that C1 was inappropriate touched by C2 at the facility, may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated. An exit interview was conducted, appeal rights discussed, and a copy of this report was provided to Licensee Beverly Boone.

Investigation Findings:
13On August 27, 2021 at 1:13PM, Licensing Program Analyst (LPA) Carol Anderson met with Licensee Beverly Boone to deliver the findings for the above stated allegation regarding the minor engaged in inappropriate touching of another minor in the home as listed on the Confidential Names List, LIC 811. The investigation was initiated on April 15, 2021 at the facility. There were no deficiencies noted at that time. During the investigation, LPA interviewed five of five clients (C1 through C5), five of three staff (S1 through S3). LPA reviewed C1 and C2's Appraisal Needs and Services Plans as well as Special Incident Reports. The Department received a complaint on April 8, 2021, alleging minor engaged in inappropriate touching of another minor in the home. Confidential interviews revealed conflicting statements; C2 has been licking C1's face and touching C1's chest every night during bedtime since first placed at the facility, and C2 did not touch C1. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Carol Anderson 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, METROPOLITAN DR. # FACILITY NAME: MILESTONE GROUP HOMEFACILITY NUMBER: VISIT DATE: 08/27/2021

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

met_with: Beverly Boone


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Narrative:
S4 was removed from the schedule immediately and the agency terminated the employee's employment, as of 10/30/2021. Based on confidential interviews, the preponderance of evidence standard has been met regarding the allegation that S4 made inappropriate comments towards a client, therefore the complaint allegation is substantiated. The facility is cited for violation of Interim Licensing Standards (ILS) v. Personal Rights 87072(c)(10). This posed a potential Health, Safety, or Personal Rights risk to children in care. A copy of this report was provided to and reviewed with Beverly Boone, Executive Director, along with the appeal rights and the LIC 811. A signed copy of the report will be kept in the Facility file. resulted in C1 and C4 being unsupervised in a bedroom and had sex. The interviews that were provided to the LPA were not consistent regarding the allegation that staff were not properly supervising minors and did not provide any further specific details regarding staff supervision. Based on interviews the staff did not properly supervise minors while in care, resulting in minors having inappropriate interactions, which may or may not have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Beverly Boone, Executive Director. A copy of this report will be placed in the Facility file.

Investigation Findings:
13On April 29, 2022, at 12:55 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Beverly Boone, Executive Director, of Milestone to discuss the investigative findings for the allegation noted above. LPA Carol Anderson conducted an inspection with the facility on June 7, 2021, at 10: AM. No deficiencies were observed. During the investigation, LPA Carol Anderson and LPA Charmaine Linley interviewed four clients (C1, C2, C3, C5) and two staff (S1, S2). LPA Anderson and LPA Linley reviewed the following documents C1's Appraisal Needs and Services Plan, C1's Child-Family-Team Meeting notes, staff scheduled for January-February 2021, and staff contact information On May 28, 2021, Community Care Licensing (CCL) received an allegation that staff members had made inappropriate comments toward the minor. It was alleged that two staff members had told clients "you will never amount to anything and you'll end up in jail or on the streets." Based on confidential interviews, S4 made inappropriate comments towards several clients, and S5 overheard S4 telling C2 to "shut up." SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: MILESTONE GROUP HOMEFACILITY NUMBER: VISIT DATE: 04/29/2022

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

met_with: Beverly Boone, Executive Director


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Narrative:
placed a Facetime call to the staff inside of the facility. Regarding the allegation that the facility has pests. Confidential interviews report that the facility has slugs, roaches, and mice. Confidential interviews reveal they have seen roaches in the bathroom and hallways. Confidential interviews reveal that they have seen mice in the house at night. Confidential interviews and documents revealed that there were monthly pest control services at the facility, however, the dates of the services were after the facility was made aware of the allegation roaches, slugs, and mice were present in the facility. Based on confidential interviews and record review of facility documentation, the allegations that the staff is not properly supervising the minors and the facility has pests. are substantiated which poses a potential health, safety, and personal rights risk to clients in care. The preponderance of evidence standard has been met. The facility is cited for violation of the California Code of Regulations, Title 22, Division 6, Chapter 1, Article 6, 80078(a) Responsibility for Providing Care and Supervision. The facility is cited for violation of the California Title 22, Division 6, Chapter 1, Article 07, regulation 80076(a)(17) Food Service. A copy of this report was provided to and reviewed with Beverly Boone, Executive DIrector, along with the appeal right and the LIC 811. A signed copy of the report will be kept in the Facility file. or paraphernalia. Confidential interviews revealed that staff increases their supervision level if they suspect clients are using drugs. Other confidential interviews revealed that clients have smoked in the bathroom and outside of their bedroom doors and covered it up with perfume. Other confidential interviews revealed that staff have smelled smoke in the facility and had not asked the clients if someone was using drugs. Regarding the allegation that the facility vehicle is not in proper driving condition. Confidential interviews and reports revealed that the facility van was replaced in July 2021 and has not had any issues since the transmission was replaced. Other confidential interviews revealed the vehicle struggles and makes sounds while driving up hills. Confidential interviews revealed that clients are offered the opportunity to clean the vehicles once a month and earn an extra allowance. Other confidential interviews revealed that staff will take the vehicle to an automatic car wash and pay for it themselves. Based on interviews and information obtained, the allegations that minors are using drugs on the facility premises, and the facility vehicle is not in proper driving condition, may or may not have occurred, however, it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. A copy of this report was provided to and reviewed with Beverly Boone, Executive DIrector , along with the appeal right and the LIC 811. A signed copy of the report will be kept in the Facility file

Investigation Findings:
13On April 29, 2022, at 12:21 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Beverly Boone, Executive DIrector of Milestone to discuss the investigative findings for the allegations noted above. LPA Carol Anderson conducted an inspection of the facility on July 19, 2021, at 11: AM. No deficiencies were observed. During the investigation, LPA Carol Anderson and LPA Charmaine Linley interviewed three clients (C1, C2, C3) and two staff (S1, S2). LPA Anderson and LPA Linley reviewed the following documents C1's Appraisal Needs and Services Plan, Staff Schedule, Pest Control Invoices from 2020-2021, and notes from the communication log about C1's incidents. On July 9, 2021, Community Care Licensing (CCL) received allegations that the staff is not properly supervising the minors and the facility has pests. Confidential interviews and documents reviewed indicated that two clients were left unsupervised outside to go on a walk together, which resulted in one minor placing another minor in a grocery cart and pushing them down a hill. Confidential interviews revealed that staff was not aware the clients were going down the hill in a cart until one of the clients SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: MILESTONE GROUP HOMEFACILITY NUMBER: VISIT DATE: 04/29/2022

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

met_with: Beverly Boone, Executive DIrector


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Narrative:
substantiated. This posed a potential Health, Safety, or Personal Rights risk to C3 in care, the facility will be cited for violating Interim Licensing Standards, STRTP, Article 06, 87070(g) Client Records. A copy of this report was provided to and reviewed with Beverly Boone, Executive DIrector, along with the appeal rights and the LIC 811. A signed copy of the report will be kept in the Facility file.

Investigation Findings:
13On April 29, 2022, at 12:01 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Beverly Boone, Executive DIrector, of Milestone to discuss the investigative findings for the allegation noted above. LPA Carol Anderson conducted an inspection with the facility on September 9, 2021, at 11: AM. No deficiencies were observed. During the investigation, LPA Carol Anderson and LPA Charmaine Linley interviewed one client (C1) and two staff (S1, S2). On August 31, 2021, Community Care Licensing (CCL) received an allegation that staff did not safeguard the minor's personal information. The staff is alleged to have used C1's name and date of birth at an Independent Living Program Event for C2 to obtain a gift card. Confidential interviews revealed that S4 did use C1's name and date of birth since they were eligible to receive a gift card, while C2 was not eligible. During this incident, C2 was able to obtain C1's confidential birth name. Based on confidential interviews, the preponderance of evidence standard has been met regarding the allegation that S4 did not safeguard C1's personal information, therefore the complaint allegation is SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: MILESTONE GROUP HOMEFACILITY NUMBER: VISIT DATE: 04/29/2022

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


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Narrative:
access to them. Regarding the stove is in disrepair. Reports alleged that the stovetop has caught fire and the burners are loose. Based on confidential reports, all the stovetop burners do not work, and they must be adjusted multiple times before they work. Confidential interviews revealed the maintenance people have worked on the stovetop, despite the repairs, it was revealed the burners do not all consistently work. Based on LPA's observation, the back-left burner of the facility does not work. Based on confidential interviews, the preponderance of evidence standard has been met regarding the allegations that hazard tools are left accessible to clients, and the stove is in disrepair therefore the complaint allegations are substantiated. This posed a potential Health, Safety, or Personal Rights risk to clients in care, the facility will be cited for violating California Title 22, Division 6, Chapter 1, Article 07, Regulation 80087(g) Building and Grounds and Regulation 80076(a)(19) Food Service. A copy of this report was provided to and reviewed with Beverly Boone, Executive DIrector, along with the appeal rights and the LIC 811. A signed copy of the report will be kept in the Facility file. residents. Other confidential interviews revealed maintenance staff called residents "princesses" and made them feel uncomfortable. There were no witnesses of the maintenance staff speaking inappropriately to the residents. Based on confidential interviews, although the allegation that staff called residents inappropriate names may or may not have occurred, however, it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. A copy of this report was provided to and reviewed with Beverly Boone, Executive DIrector , along with the appeal right and the LIC 811. A signed copy of the report will be kept in the Facility file.

Investigation Findings:
13On April 29, 2022, at 11:31 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Beverly Boone, Executive DIrector, of Milestone to discuss the investigative findings for the allegations noted above. LPA Carol Anderson conducted an inspection of the facility on December 6, 2021, at 11: AM. No deficiencies were observed. During the investigation, LPA Carol Anderson and LPA Charmaine Linley interviewed five clients (C1, C2, C3, C4, C5) and three staff (S1, S2, S3). LPA Anderson and LPA Linley reviewed the following documents client roster, C1's food log, C1's monthly weight records, facility maintenance log, and staff roster. On December 6, 2021, Community Care Licensing (CCL) received an allegation that hazard tools are left accessible to residents, and that the stove is in disrepair. Reports alleged that while the maintenance people are working at the facility, they have left out tools, including a saw, and nails on the ground. Based on confidential interviews, the maintenance people have left out tools and supplies and have been told on several occasions to secure and lock up their tools and supplies, so the clients do not have SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: MILESTONE GROUP HOMEFACILITY NUMBER: VISIT DATE: 04/29/2022

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:


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Narrative:
property. Other confidential interviews entail that the staff did smoke in the facility and on the grounds. Confidential interviews revealed two staff members smoke, and they have been observed smoking while in their personal vehicles away from the facility. There are no witnesses to this allegation. Regarding the allegation that staff did not protect minors' belongings. The allegation entailed that teddy bears and an I-pad were stolen from a C3's bedroom and money from various clients. Confidential interviews reported that the I-pad was returned to the client one week later. Confidential interviews revealed that clients would misplace their money and accuse others of stealing their money and later the clients would find their money. Confidential interviews entailed that there were no reports of stolen money or belongings to the staff. Other confidential interviews entailed that clients never found their belongings that were allegedly stolen. Regarding the allegation that staff shows favoritism to clients. Confidential interviews revealed that staff shows favoritism to certain clients not getting consequences after using drugs, taking them on a one-on-one outing in the community, and treating them nicer than the other clients. Confidential interviews revealed conflicting reports; clients are not given consequences and clients are placed on restrictions for using drugs. Confidential interviews revealed that S5 took C5 to cultural events in the community, as both persons are of similar cultural backgrounds. Confidential interviews revealed that certain clients are more talkative and engage with staff that clients perceive as favoritism. Confidential interviews revealed that there was no specific client that was given preferential treatment. Based on interviews, the allegations that staff smoked inside of the facility and outside of the facility next to the client's exit doors, staff did not protect minors' belongings, and staff shows favoritism to clients may or may not have occurred, however, it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated currently. A copy of this report was provided to and reviewed with Beverly Boone, Executive Director, along with the appeal right and the LIC 811. A signed copy of the report will be kept in the Facility file.

Investigation Findings:
13On April 29, 2022, at 10:50am, Licensing Program Analyst (LPA) Charmaine Linley made an unannounced complaint inspection at the facility. LPA Linley met with Beverly Boone, Executive Director, to discuss and deliver the investigative findings for the allegations noted above. LPA Linley conducted an unannounced inspection of the facility on April 19, 2022. No deficiencies were observed. During the investigation, LPA Linley interviewed four clients (C1, C3, C4, C5) and four staff (S1, S2, S3, S4) C2 was ill in bed and unable to be interviewed (see confidential name list, LIC 811, dated 04/29/22). LPA Linley reviewed the following documentation: C Needs and Services Plan, dated 09/30/2021, C Discharge Report, dated 10/04/2021, Copy of the House Rules, C Discharge Inventory signed 10/01/2021. On April 19, 2022, the Department received an allegation that staff smoked inside of the facility and outside of the facility next to the client's exit doors, staff did not protect minors' belongings, and staff shows favoritism to clients. Confidential interviews revealed conflicting statements: Confidential interviews revealed that staff has never been observed smoking inside of the facility or on the facility UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: MILESTONE GROUP HOMEFACILITY NUMBER: VISIT DATE: 04/29/2022

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

met_with: Beverly Boone, Executive director


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Narrative:
An exit interview was conducted, appeal rights explained and a copy of this report was provided to Beverly Boone, along with the LIC 811.

Investigation Findings:
13On November 4, 2022 at 10:40am, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced inspection to the facility to deliver the findings of the above allegation. LPA met with Beverly Boone. LPA Daniel Garcia conducted an inspection of the facility on November 09, 2021 at 11:20 am and no immediate deficiencies were observed. Four of four children (C1, C2, C3, C4), four staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that staff #1 (S1) made an inappropriate comment to C1. Confidential interviews reported that on October 29, C1 and S1 were engaging in a conversation about another staff member. Confidential interviews reported that S1 then made an inappropriate comment, " screw you" to C1. All of the persons interviewed corroborated this information. Based on record review and interviews S1 did make an inappropriate comment C1. The preponderance of evidence standard has been met, therefore the allegation S1 pushed C1 is found to be Substantiated. This poses an Potential Health, Safety or Personal Rights risk to the children in care. The STRTP is being issued a citation for violations of the Interim Licensing Standards, Chapter 7.5, Version 3.1, Section 87072(d)(10) Personal Rights. See attached LIC 9099D for cited deficiency. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: MILESTONE GROUP HOMEFACILITY NUMBER: VISIT DATE: 11/04/2022

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


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Narrative:
Based on record reviews and confidential interviews, C1 sexually exploiting themselves on November 3, 2022. The details gathered from police report did not provide sufficient evidence to prove or disprove the allegations that facility staff are not preventing C1 from sexually exploiting themselves online and in person while in care. Therefore, the allegations are unsubstantiated. LPA conducted an exit interview and provided a copy of this report along with appeal rights to Beverly Boone, Executive Director.

Investigation Findings:
13On January 6, 2023 at 2: PM, Licensing Program Analysts (LPA's) Lucero Jauregui and Eduardo Barragan conducted a complaint inspection at Milestone and met with Beverly Boone, Executive Director and Desiree West, Clinical Director. The purpose of the inspection was to deliver the findings for the above complaint allegations. LPA Jauregui conducted an inspection of the facility on November 29, 2022, and no deficiencies were noted. During the investigation, LPA Jauregui reviewed needs and services, shift notes, incident reports and interviewed one client (C1), five staff (S1-S4,S6), and one county social worker (A1). LPA attempted to interview one staff (S5). However, after attempts LPA was unsuccessful. On November 21, 2022, the Department received a complaint report, with allegations that facility staff are not preventing minor from sexually exploiting themselves online and in person while in care. Confidential interviews revealed conflicting statements as to staff intervening prior to C AWOLing from the facility. In addition, there was no safety plan documented in C1's file. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: LUCERO JAUREGUI 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SO. Cal Sc/res, Metropolitan Dr. # FACILITY NAME: MILESTONE GROUP HOMEFACILITY NUMBER: VISIT DATE: 01/06/2023

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


facility_name: MILLIE'S YOUTH SERVICES

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Investigation Findings:
13Licensing Program Analyst (LPA) Christopher Rollins conducted a follow-up complaint inspection at Millie Youth Services and met with Jasmine Remson Facility Manager (FM). The purpose of the inspection was to deliver the finding for the above complaint allegation. During the course of investigating the allegation, LPA Rollins conducted confidential interviews with facility staff, clients, social workers and conducted clients file review. Confidential interviews reveal conflicting stories about facility staff choked a client in care. Based on interviews and documentation there was not enough evidence to prove that facility staff choked a client in care. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that facility staff choked a client in care ,therefore the above allegation is unsubstantiated. Exit interview conducted with FM and LPA left report at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: Christopher Rollins LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

met_with: Jasmine Remson- Facility Manager


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

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

met_with: Tanya Lashley


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Investigation Findings:
13This is an amended report, original date was 10/19/22. Licensing Program Analyst (LPA) amended this report due to including additional finding on this LIC 9099. On 11-8-22 1: PM, Licensing Program Analyst (LPA) George Karkazis conducted a follow-up complaint inspection at Millie's Youth Services and met with Tonya Lashley, Facility Manager. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the course of the investigation, LPA conducted confidential interviews and documentation research. An incident had occurred on 9-17-22 at approximately 7: PM. There was a verbal altercation that was de-escalated while in the presence of authorities. Based on document review, there was no evidence of a physical altercation. Based on confidential interviews, inconsistent information was provided, only an unintentional reflexive touch may have occurred during the verbal altercation. While authorities asked staff questions regarding client safety, the client misunderstood staff's response as being derogatory. Although the above allegations may have happened or is valid, there is not a preponderance of the evidence to prove that; staff hit minor in care, staff shoved minor in care, and staff speak inappropriately to minor(s) in care. Therefore, these allegations are UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was given to Tonya Lashley, Facility Manager.. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Mendoza LICENSING EVALUATOR NAME: George Karkazis 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 3

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

met_with: Millie Winn, Licensee