facility_name: ROP QUALIFYING HOUSE MT. RUBY

raw_content:
Narrative:
The allegation that staff gave a foster child non-prescribed medication for illicit use is related to C1 obtaining pills from S1. While S1 denied giving the medication to C1, S1 did tell law enforcement that C1 might have "helped themselves to S1's medications". Without information from S1, there is no plausible explanation for C1 to have knowledge of S1 taking any medication, of C1 knowing that S1 had medication in the facility or knowing what medication(s) S1 was taking. As a result of the investigation and interviews conducted, the allegations that staff sexually abused a foster child and that staff gave a foster child non-prescribed medication for illicit use are SUBSTANTIATED at this time meaning that the allegation is valid because the preponderance of the evidence standard has been met. Facility was cited for Interim Licensing Standards 87072(d)(11) Personal Rights. The facility has a responsibility to accord personal rights to all children in care including the right to be free of physical, sexual, emotional, or other abuse... investigation showed that S1 sexually abuse C1 in the facility. Facility was cited for Interim Licensing Standards 87065.2(b)(1) Personnel Duties. The facility did not employ staff to appropriately supervise, protect, and care for children living in the facility at all times in that S1 provided non-prescribed medication(s) for illicit use to C1 while at the facility. Exit interview was conducted with Ms. Edwards and documents provided at the conclusion of the inspection.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 10/20/21 at 9: AM and met with Tracy Edwards, Administrator to discuss the findings for the complaint allegations as stated. LPA informed Ms. Edwards that the investigation included an initial complaint inspection on 7/8/21 by Investigator Juan Barajas. All interviews with staff, clients, law enforcement, social workers, reporting party and other personnel was conducted by the Investigations Branch for the Department from 7/8/21 to 9/30/21. The allegation that staff sexually abused a foster child is related to a disclosure made on 6/30/21, by C1 (see LIC811 dated DATE) that C1 had engaged in sexual intercourse with S1 in the staff room at the facility. When interviewed by law enforcement, S1 admitted to investigating officers on 6/26/21, that this allegation was true. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., Ste Sacramento, CA Facility Name: Rop Qualifying House Mt. RUBYFACILITY NUMBER: VISIT DATE: 10/20/2021

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


state: CA

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews revealed that S1 told numerous youth that upon completion of their program, they could return to Nevada to live with S1. Interviews revealed that there was no discussion of anything sexual but that they didn't know S1's intentions, making them feel uncomfortable at the mention of this. When staff were interviewed, they informed LPA that there was a company policy prohibiting contact with youth following their exit from the program without notification and written approval by management. Interviews revealed that S1 has not disclosed this offer to management nor had there been any written permission allowing S1 to discuss this with youth in the program. Another incident of youth not feeling comfortable was when one youth was taken into the staff room to do a hair cut and being one on one with S1 in the staff room. While youth reported that nothing happened in the staff room, company policy states the staff room as an "off limits" area for youth. Youth know this which made the youth feel uncomfortable since the other hair cuts being done in the home were done in the dining area. The next allegation is about S1 "spatting water" in youth's face during a walrus impression joke. This incident had no direct witnesses and S1 failed to provide a statement related to this incident. The final allegation that S1 threatened youth, is related to S1 telling youth that if they misbehaved or didn't do as S1 asked, S1 would get their friends in law enforcement in the area to come over and taze them. Youth also reported that S1 asked them to help S1 get information on other staff to get them fired. S1 allegedly told youth that they planted contraband in youth's possessions and took photos to provide to management to sabotage youths' program. There is no evidence any of this happened and S1 failed to provide a statement. During the course of the investigation, a youth alleged that S1 hit them with a belt one evening while in their own room and out of sight of cameras at the facility. The youth claimed to have not disclosed this happening because S1 told youth that they would not be believed. Youth also stated they were not a snitch and could handle it themselves. During interviews, another youth in the home disclosed hearing the belt strike the youth and heard the youth get upset and scream at S1 for striking them with the belt immediately after it happened. A staff also alleged that S1 bragged about striking another youth in the stomach. While there is not a significant amount of evidence in all of these allegations, the totality of the allegations and the number of recounts of the same or like information that came out as a result of the investigation demonstrates the overall character of S1. In addition to S1 not making themselves available to provide input despite the multiple attempts by LPA Hill, give preponderance to the allegations against S1. As a result of the information disclosed and the lack of response from S1, the allegations that S1 violated youth's rights, spat in a youth's face, and threatened or intimidated youth are SUBSTANTIATED meaning that the "preponderance of the evidence" standard has been met. The facility was cited for Personal Rights 87072(a)(11) as children have the right to be free physical abuse, intimidation, threat, ridicule, and coercion. On at least one occasion, S1 struck a youth in care with a belt. S1 also disclosed to a staff that they had punched a youth in the stomach. S1 intimidated and threatened youth in care to have friends in law enforcement come to the facility to taze youth to get youth to comply and behave. S1 also intimidated and threatened youth to plant contraband in their possessions to get them into trouble or to fail their program. Exit interview was conducted and documentation was provided to the facility.

Investigation Findings:
13Licensing Program Analyat (LPA) Tamara Hill made an unannounced complaint visit to Business Park Drive, Minden, NV on 3/2/22 at 12: PM and met with Tracy Edwards, Administrator to discuss the findings. LPA informed Ms. Edwards that the initial investigation of the allegations occurred on 11/23/21. LPA interviewed children and staff at the school site on 11/23/21. LPA interviewed additional staff via phone on 2/10/22 and attempted to contact S1 eight times from 2/11/22 to 2/23/22, using email, text messages and phone messages. LPA did speak with S1 on 2/18/22 and S1 stated that they were sick with COVID since 2/11/22. LPA asked staff to please contact LPA on 2/22/22 to discuss a time and date to conduct an interview to allow S1 to give input about the allegations. LPA then contacted S1 via text message and phone message on 2/23/22, but S1 did not respond to the multiple requests for interview. The first allegation is related to S1 violating personal rights of youth in care. Youth reported feeling uncomfortable around S1 due to some of the following issues. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., Ste Sacramento, CA Facility Name: Rop Qualifying House Mt. RUBYFACILITY NUMBER: VISIT DATE: 03/02/2022

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

report_type: Complaint Investigation

met_with: Tracy Edwards, Administrator

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
C1 was observed to be red in the face and have a swollen or bloody lip following the incident. It was also alleged that this incident was not reported to Licensing as required. LPA obtained a copy of a draft incident while at the agency on 5/16/2022. This report was not sent to Licensing. When staff reviewed the cameras at the facility, it was disclosed that there were no staff supervising the youth in the living area at the time of the incident which allowed the youth the opportunity to step outside, outside of view of any cameras at the facility, and engage in the altercation. As a result of the interviews conducted and review of the cameras, the allegations that there was a lack of supervision allowing the youth to engage in a physical altercation and that the facility failed to report the incident to Licensing as required are SUBSTANTIATED at this time meaning that the "preponderance of the evidence" standard has been met. The allegation that a lack of supervision resulted in a youth to leave the facility undetected is related to an incident that happened on 4/26/22 in which C2 was able to leave the facility and be gone for multiple hours without staff knowing. When interviewed, C2 admits to leaving the facility around midnight on 4/26/22 but S1 failed to notice that C2 was gone until AM. When the administrator reviewed the cameras for the evening of 4/25/22 to the early morning of 4/26/22, S1 failed to conduct the nightly checks according to the agency policy which requires youth to be checked on every 15 minutes and for staff to verify that they see skin when checking on youth. As a result of the information obtained and interviews conducted, the allegation that a lack of supervision resulted in a youth leaving the facility undetected and being gone for hours is SUBSTANTIATED at this time meaning that the "preponderance of the evidence" standard has been met. As a result of the allegations substantiated, the facility was cited for Title 22, California Code of Regulations, General Regulations, 80078(a) Responsibility for Providing Care and Supervision as staff failed to supervise youth appropriately to prevent an altercation that took place on 5/5/2022 between C1 and C2, out of camera view and with no staff present. In addition, staff failed to appropriately supervise youth on 4/26/22 leading to C2 being able to leave the facility undetected and being gone for approximately two hours prior to staff knowing. The facility was also cited for Title 22, California Code of Regulations, General Regulations, 80061(a) Reporting Requirements as the agency failed to report the altercation between C1 and C2 that happened on 5/5/2022. The incident was not provided to Licensing until LPA Hill obtained a copy while initiating the complaint investigation on 5/16/2022. Exit interview was conducted with Ms. Edwards and documents were provided via email along with appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 9/1/22 at 11: AM and met with Tracy Edwards, Administrator to discuss the findings of the allegations. LPA Hill informed Ms. Edwards that the complaint investigation included an initial inspection at the facility on 5/16/2022 and collateral inspection at the administrative offices in Minden, NV, to interview staff and clients involved in the incidents. LPA interviewed C1, C2, and C3 (see LIC811 dated 9/1/22) and staff while at the administrative offices and obtained documentation related to the clients and incidents under investigation. LPA informed Ms. Edwards that the allegation regarding lack of supervision resulting in a serious altercation between clients happened on 5/5/2022 while at the facility in which two clients stepped out on the back patio of the facility and engaged in a physical altercation without staff detection. When interviewed, the clients refused to disclose that anything had happened but there was evidence that something had happened as SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., Ste Sacramento, CA Facility Name: Rop Qualifying House Mt. RUBYFACILITY NUMBER: VISIT DATE: 09/01/2022

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


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
neighbors, with the youth present, telling the neighbor to "take [their] racist ass back home" as they thought the youth walking were being racially targeted by the neighbors. Staff admitted to making the inappropriate comment out of anger toward the neighbors due to the perceived racial targeting. During confidential interviews, it was confirmed that S1 did make the inappropriate statements to the neighbors instead of attempting to intervene in an appropriate manner or attempting redirect the youth back to the facility without a confrontation. As a result of the confidential interviews and information received, the allegation that staff shouted racial epithets at the neighbors, is SUBSTANTIATED meaning that the "preponderance of the evidence" standard has been met. Facility was cited for violation of Short Term Residential Therapeutic Program, Interim Licensing Standards, Section 87072(c)(10) Personal Rights as youth are to be accorded the right to dignity in their personal relationships with staff and other persons. This did not happen as the youth were subjected to an inappropriate interaction between the staff and the neighbors. Exit interview was conducted and documentation was provided to the facility. The allegation about the staff not supervising the youth is related to whether or not staff were supervising youth while they were walking on the street and playing ball in front of the facility. Confidential interviews were not consistent about where staff were at to supervise the youth while the youth were on the street walking and playing ball. Some of the interviews stated that the staff were not present but other interviews stated that the staff were supervising the youth from the facility driveway as they walked approximately 300 yards down the street as part of their exercise program and played ball in front of the facility. The allegation that the facility is not adhering to the good neighbor policy relates to two separate issues wherein the community members feel that the youth and staff working in the facility are not being friendly to the neighbors, not respecting the right to privacy, and being respectful of local ordinances where the facility is located. While the good neighbor policy is not addressed in Title Regulations and thereby not a violation of the regulations that govern the facility, these incidents could have been addressed within the facility's Neighborhood Complaint Policy, the community members could have contacted a facility representative when these issues surfaced. Community members have expressed concern that they have brought issues to the attention of staff at the facility but the information reportedly is not being provided to the administrative staff. The facility shall provide Neighborhood Complaint Policy to neighbors/community members for future reference. As a result of the investigation conducted, confidential interviews, and other documentation received, the allegations that youth were wandering unaccompanied by staff and that the facility was not adhering to a good neighbor policy are UNSUBSTANTIATED at this time meaning that the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview was conducted and documentation was provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 6/27/23 at 2: PM and met with Tracy Edwards, Program Director/Administrator to discuss the findings of the allegation as stated. LPA Hill informed Ms. Edwards that the investigation included an initial inspection on 4/26/23, where three youth and three staff persons were interviewed. LPA Hill requested a copy of the police report from Alpine County Sheriff's Office on 4/26/23, for an incident that occurred on 4/11/23. The police report was received 4/27/23. A subsequent inspection was conducted on 6/6/23, where personnel records were reviewed. LPA Hill informed Ms. Edwards that the allegation that staff shouted racial epithets at the neighbors is related to an incident that took place in front of the facility on 4/11/23, where the youth were stopped by the neighbors while walking on the street. S1 (see LIC811 dated 6/27/23) subsequently confronted the SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., Ste Sacramento, CA Facility Name: Rop Qualifying House Mt. RUBYFACILITY NUMBER: VISIT DATE: 06/27/2023

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:

complaint_status: unsubstantiated


raw_content:
Narrative:
current psychiatrist was terminating their contracted psychiatry services as of August 2023. In July 2023, the agency found and began the process of on-boarding a new psychiatrist, but the process was lengthy, and the agency did not have the new psychiatrist on board until November 2023, meaning the youth did not have the required monthly psychiatry consultations for the months of September 2023 and October 2023 but the agency continued to accept youth, specifically, C1 (see LIC811 dated 3/25/24) was admitted 10/23/23. The agency was able to provide documentation including emails and correspondence between the agency's HOS, Placer County, the new contracted provider, Health Link Now, and the psychiatrist from July 2023 through November 2023, indicating that the agency was actively trying to get the new psychiatrist through the contract and on boarding process to provide services to youth in care. In addition, in anticipation of not having the psychiatrist on board in time, Head of Service (HOS) did reach out to Barton Psychiatry in South Lake Tahoe on 8/5/23 but were informed that the wait time would be until January 2024, and Washoe County (Nevada) Behavioral Health informed the agency that they could not provide services to the agency's youth. HOS presumed this was due to the youth being California youth and not from Nevada. The new psychiatrist was providing psychiatry services to youth in care as of November 14, 2023. LPA Hill was informed that during the time with no psychiatry services, the agency had prepared in advanced and did have prescription refills for all youths' medications and no youth went without medications or had lapses in medications during the months of September 2023 or October 2023. The allegation that the facility did not ensure client's medical and/or mental health needs were met is related to the same allegation as stated regarding youth having the required psychiatry consultations prescribed in regulation. When reviewing C2 and C3's paperwork, it was indicated that all medical and mental health services were provided except for the psychiatry consultations as described. C1 was admitted in the facility and did have the required psychiatry appointments as required as they were part of C1's negotiated services with the placement agency. Interviews indicate that the facility did ensure all youth had consultations with doctor, dentist, and optometry as needed while at the facility and that the agency did ensure that therapy, and other mental health services were being provided during youths' time at the facility. As a result of the investigation, documentation received, interviews conducted, the allegations that the facility did not provide clients in care with consultation from a psychiatrist as required and that the facility did not ensure medical and/or mental health needs were met is UNSUBSTANTIATED at this time as the facility did employ active efforts in locating and on boarding the new psychiatrist and were providing other mental health services to youth in care. Unsubstantiated means that the allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. Exit interview conducted with Ms. Scott and documentation provided, including appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 3/25/24 at 3: PM and met with Alina Scott, Head of Service to discuss the complaint findings as stated. LPA Hill informed Ms. Scott that investigation included an initial inspection at the facility on 10/27/23 and subsequent inspection 2/15/24. Two youth were interviewed 11/17/23 and the placing agency Public Health Nurse was interviewed 1/11/24. The facility administrator and Head of Service were interviewed 2/15/24. Documentation received including placement documents, Needs and Services Plans, and documentation related to the agency's efforts to onboard a psychiatrist dating from July 2023 to November 2023. The allegation the facility did not provide clients in care with consultation from a psychiatrist as needed is related to the facility not having a contract with a psychiatrist and youth not being provided the psychiatry appointments for the months of September 2023 and October 2023 as required by regulation. Confidential interviews conducted demonstrated that the agency was given a 60-day notice in June 2023 that their UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE MT. RUBYFACILITY NUMBER: VISIT DATE: 03/25/2024

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

met_with: Alina Scott, Head of Service


raw_content:
Narrative:
August 2024, not all youth were immediately assigned to the new therapist, S2. When it was finally decided to assign all youth to S2 and begin their transition, S2 noted that there were three to four weeks' of missing or undone therapy documentation to facilitate this change in therapists. S2 noted that in discussing this with the agency's management, S2 was directed to "start new" with all of the youth being added to S2's caseload, which was about half of all the youth they had in care at that time. S2 indicates that this meant going back and completing documents for all youth as if they were brand new, even if they had been in care for some time, as there were incomplete and/or undone documented therapy notes. Subsequent interviews with other agency personnel indicates that the agency will not be returning S1 to their employment position within the agency. As a result of interviews conducted and documentation reviewed, the allegation that staff did not ensure that youth are provided mental health services is SUBSTANTIATED at this time meaning the "preponderance of the evidence" standard has been met. The facility cited for Interim Licensing Standards for Short Term Residential Therapeutic Programs, regulation 87072(d): Personal Rights. Youth have the right to access and receive medical...mental health, and substance use disorder services...with reasonable promptness that meets the needs of the child...Confidential interviews conducted with staff and youth in care indicate that youth were without mental health services, specifically therapy sessions, for three to four weeks. Further interviews indicate when therapy sessions did resume for youth in care, there were therapy session notes not documented as required by the previous therapist for a reported period of up to four weeks. Exit interview was conducted and documentation was provided to Ms. Edwards.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 1/7/25 at 10: AM and met with Tracy Edwards, Administrator, to discuss the findings of this complaint investigation. LPA Hill informed Ms. Edwards that the complaint investigation included an initial inspection of the facility on 9/5/24, with subsequent collateral inspections to the administrative offices on 9/20/24, 10/25/24, and 11/26/24, where interviews were conducted with administrator, therapist, and youth in care. During the course of the investigation, LPA Hill also interviewed youths' social workers. The allegation that staff did not ensure that youth are provided mental health services is related to the youth in care not being provided therapy as dictated in the agency's program statement. While the documentation provided indicates that some youth were seeing the previous therapist, S1, who went out on leave in SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE MT. RUBYFACILITY NUMBER: VISIT DATE: 01/07/2025

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


raw_content:
Narrative:
Facility staff acknowledge that they knew about C1's desire to exit the program as soon as possible but had not communicated directly with a responsible party to arrange for exit or transportation. C1 had a visitation scheduled at the school site with another family member on 8/31/24, where C1 was going to ask that family member for a ride back to the family's home. The agency made tentative alternate plans to provide the transportation for the youth to the family's home on 9/3/24, if the family member did not agree to provide that transportation. During the investigation, it was discovered that staff did not communicate discharge plans, including the family member transporting C1 from the program, with C1's parent/guardian to ensure that C1 had a place to stay upon arrival. Further confidential interviews indicate that the relationship between C1 and their parent/guardian was "difficult", and staff did not verify that this was an appropriate plan for C1 at the time of their discharge. As a result of the lack of an appropriate discharge plan, C1 left the facility on an unauthorized absence and when law enforcement was called and subsequently arrived, they provided transportation to C1 to a public location where C1 was left. As a result of the investigation and documentation provided, the allegation that staff did not assist C1 with their transportation needs while in care is SUBSTANTIATED meaning the "preponderance of the evidence" standard has been met. Facility was cited for Interim Licensing Standards, regulation 87068.4(c) Removal and/or Transfer Procedures as the short-term residential therapeutic program shall provide trauma-informed support and transition services including the alignment and coordination of transportation and other foster youth services as required. The facility identified that C1 was going to exit the program but did not arrange the transportation services needed for that transition. Exit interview conducted with Ms. Edwards and documentation was provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 1/7/25 at 10: AM and met with Tracy Edwards, Administrator, to discuss the findings of this complaint investigation. LPA Hill informed Ms. Edwards that the complaint investigation included an initial inspection of the facility on 9/5/24, with subsequent collateral inspections to the administrative offices on 10/25/24, and 11/26/24, where interviews were conducted with administrator and therapist, and documents were obtained. During the course of the investigation, LPA Hill attempted contact with C1 (see LIC811 dated 1/7/25) and C1's parent but they did not respond to LPA Hill's calls. The allegation that staff did not adequately assist C1 in their transportation needs while in care is related to the facility not arranging for C1 to exit the program despite knowing that C1 had expressed their desire and intent to leave the program once they became of age to make that decision. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE MT. RUBYFACILITY NUMBER: VISIT DATE: 01/07/2025

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


raw_content:
Narrative:
The allegations that staff did not prevent clients from having access to medicine is related to reports from clients in care that C3, C6, and C7 (see LIC811 dated 2/6/25) brought in over the counter medications without authorization or knowledge of the facility staff and administration. Confidential interviews revealed that clients found it "easy" to steal the over the counter medication when going into stores during outings. Some clients brought the over the counter medication from home visits or were accessing the over the counter medication from the facility's medication box when administering medication for clients. The allegation that staff smoke with clients in care is related to the allegation that staff member(s) have provided vape pens containing nicotine products and wax pens (also called weed pens, dap pens, or vapes containing cannabis products) to clients in the facility. Confidential interviews indicated that clients were being provided these items to smoke or ingest by staff working at the facility. While the named staff person(s) declined to be interviewed, the confidential client interviews revealed that more than one client received or used these devices as offered or provided by the staff person(s) while working at the facility. The allegation that staff make inappropriate comments towards clients is related to remarks made by staff person(s) that are not trauma informed. Confidential interviews indicated that while most staff are interacting with clients in a trauma informed manner, not all staff are using trauma informed language when interacting with clients. Confidential interviews with clients indicate that some staff do make remarks to clients when frustrated or overwhelmed. Confidential interviews indicate some of the remarks made to clients include that clients need to "stop bitching", threats to "beat [client's] ass", making disparaging remarks about client's biological families, "catch their fade" (meaning to fight them or be prepared to get beat up), to name a few. The allegation that staff are disclosing personal information about client(s) is related to an allegation that S7 disclosed personal and sensitive information about client(s) either in conversations with staff where clients were present to hear or directly to other clients in care. Confidential interviews with clients revealed certain information was only disclosed to S7 during confidential therapy sessions but revealed to other clients during their confidential sessions. Confidential interviews with staff indicated that information disclosed during confidential therapy sessions was also disclosed to staff working directly with clients in care. The allegation that staff did not prevent a client from contaminating another client's food is related to an allegation previously investigated on April 10, 2024. This investigation resulted in a citation for not providing supervision during food preparation. As a result of the investigation conducted and citation issued, this allegation was not investigated again as there was no new evidence provided. As a result of the investigation conducted by the Department's Investigation Branch and by LPA Hill, including an investigation by the Investigation Branch, confidential interviews of staff and clients, and review of the documents obtained, the allegations that staff did not prevent minors from accessing a drug, from having access to medication, staff smoking with minors in care, staff making inappropriate comments towards minors, and staff not preventing a client from contaminating another client's food are SUBSTANTIATED meaning the "preponderance of the evidence" standard has been met. The facility was cited for violation of Title General Regulations, Section 80087(g) Buildings and Grounds as the facility shall store items inaccessible to clients that could pose a danger if readily available. This was not done as evidenced by clients having access to ingest or "snort" a drug and/or medication. The facility was cited for violation of Title General Regulations, Section 80078(a) Responsibility for Providing Care and Supervision as the licensee did not provide care and supervision as necessary to meet the client's needs including an environment free of substances or other unauthorized items, including but not limited to vape pens and/or wax pens. The facility was cited for violation of the Interim Licensing Standards, Section 87072(c)(1) Personal Rights including the right to live in a safe, healthy, and comfortable home where they are treated with respect. The licensee did not provide a safe environment where comments and remarks made by staff interacting with clients are trauma informed and culturally relevant. Exit interview was conducted with Ms. Edwards and documentation was provided. wish to speak to probation officers, social workers, attorneys, or other similar individuals, they are given access to make phone calls while at school. While clients may be directed to wait to use the phone for a period of time, they are not denied access to phone use. The allegation that staff threaten client(s) is related to allegations that staff make threats to clients if they tell supervisors or administrative staff about things that happen in the facility. Some of the identified remarks included but were not limited to being in possession of unauthorized items while working at the facility including vapes, clients being disobedient when given direction by staff, or other staff experiencing frustration towards clients during situations happening. While confidential interviews of the clients in care indicate that staff can get "snippy", are short, and make remarks to youth, there were other confidential interviews indicating that staff are kind, gentle, and trauma informed. The allegation that staff did not prevent clients from accessing drugs is related to an allegation that one client brought an illegal substance into the facility that was later ingested by that client and another client while in the facility. Confidential interviews with both clients provided conflicting stories about being in possession of or ingestion of the illegal substance. Staff interviewed indicated they had no knowledge of an alleged illegal substance in the facility until it was alleged by another client in crisis. There was no evidence or additional interviews that could corroborate this allegation. As a result of the investigation, including interviews conducted with staff and clients, the allegations that staff denied client(s) access to a telephone, staff threatened client(s), and staff do not prevent clients from accessing an illegal substance (drug) are UNSUBSTANTIATED at this time meaning the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview was conducted with Ms. Edwards and documents provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 2/6/25 at 9: AM and met with Tracy Edwards, Administrator, to discuss the complaint allegations as stated. LPA Hill informed Ms. Edwards that the complaint investigation included an initial inspection at the facility on 9/5/24 and collateral inspections were conducted on 10/25/24 and 11/26/24. The complaint was referred to the Department's Investigation Branch, Investigator Austin Blatnick completed a partial investigation while LPA Hill conducted the remaining investigation. In total, seven youth and nine staff were interviewed. Investigator Blatnick investigated allegations including staff not preventing clients from having unauthorized access to medication and staff smoking with clients. LPA Hill investigated allegations including inappropriate comments being made to clients, personal information being disclosed to unauthorized staff or youth in care, and staff not preventing a client from contaminating another client's food. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE MT. RUBYFACILITY NUMBER: VISIT DATE: 02/06/2025

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


raw_content:
Narrative:
At the time of this incident, there was one staff in the facility with two clients in care, which did not meet the needs of the youth, based on record review. During an interview, staff confirmed the agency's agreement of always having two staff in the facility when youth were present. The allegation that staff do not provide adequate supervision resulting in a minor engaging in inappropriate activities is substantiated meaning the "preponderance of the evidence" standard has been met. Exit interview was conducted with the agency and documentation was provided.

Investigation Findings:
13Licensing Program Manager (LPM) Tamara Hill conducted a complaint inspection on 4/17/26 at 2: PM and met with Tracy Edwards, Administrator to discuss the findings of the complaint investigation. LPM Hill informed Ms. Edwards that the complaint investigation included an initial inspection at the facility on 11/14/26 by LPA Michelle Silvas and subsequent inspections on 1/28/26 and 3/9/26, were conducted to interview three staff, obtain Needs and Services, client records, and incident reports. The allegation that staff did not provide adequate supervision resulting in minor engaging in appropriate activities is related to an incident when two youths left the facility on an unauthorized absence and one youth was found on a neighbor's property, within a fenced area. Despite multiple prompts, the youth would not leave resulting in law enforcement being called to remove the youth from the yard and return the youth to the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Danielle Walker-Flores LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE MT. RUBYFACILITY NUMBER: VISIT DATE: 04/17/2026

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


raw_content:
Narrative:
Regarding the allegation that staff did not keep client information confidential is related to the facility using Artificial Intelligence (AI) to write confidential therapy notes about youth in care. Confidential interviews showed conflicting information related to the use of AI or similar platforms to write notes about youth in care. As a result of the investigation and interviews conducted, the allegations that staff mismanaged clients' medication and that staff did not keep client information confidential are unsubstantiated meaning that while the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Ms. Edwards and documentation was provided along with appeal rights.

Investigation Findings:
13Licensing Program Manager (LPM) Tamara Hill conducted a complaint inspection on 4/17/26 at 2: PM and met with Tracy Edwards, Administrator to discuss the findings of the complaint investigation. LPM Hill informed Ms. Edwards that the complaint investigation included an initial inspection at the facility on 12/2/25 by LPA Michelle Silvas and subsequent inspections on 3/9/26, were conducted to interview four staff, reporting party, client records, medication records, and incident reports. The allegations that staff staff mismanaged client medications and is related to an allegation that when youth run out of medications, medications are taken from another youth or past youth and given to other youth in care. Confidential interviews revealed conflicting information about the distribution of medication. Staff acknowledged training curricula including that when youth are out of medications, they notify case managers and write an incident report. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Danielle Walker-Flores LICENSING EVALUATOR NAME: Tamara Jensen-Hill LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ROP QUALIFYING HOUSE MT. RUBYFACILITY NUMBER: VISIT DATE: 04/17/2026

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


facility_name: ROP QUALIFYING HOUSE TALLAC

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA Tamara Hill made an unannounced annual inspection on 11/30/21 at 12: AM and met with Tracy Edwards, Program Manager, who assisted with the inspection. LPA Hill conducted a walk-through of the facility inside and out. There were no clients present and this facility is currently closed due to lack of clients at this time. LPA observed three, dual occupancy client bedrooms, two bathrooms accessible to clients, and one staff room with staff bathroom during the inspection. LPA Hill inspected and/or reviewed the following: Postings of facility license, Personal Rights Poster Disinfectants/Cleaning solutions were inaccessible There are two refrigerators but neither are plugged in at this time due to no clients There are no nonperishable or perishable foods present due to no clients Working telephone was present Carbon monoxide detectors and Smoke Detectors were functioning First Aid Kit was present and had all required components Common Room (living room) was available as was a separate room for relaxing/recreation Dining area with enough seating was present and in good condition Medication was centrally stored, locked/inaccessible but there are currently none at this time LPA observed a locked staff office/sleeping area. All documentation and equipment in the staff room is locked as is the staff room. Hot Water was between 105 -120 degree F Fire Extinguishers were observed to be last inspected on 2/8/21 and 4/1/21 (there were two present) Toilets, wash basin, bath and shower fixtures appeared to be in good repair, no leaks and delivering hot water. LPA observed there to be soap and paper towels available in the bathrooms. Laundry Facilities were available even though there are no clients Bedrooms appeared to be clean and organized with required linen and furnishings Motor Vehicle was not present due to the lack of clients Facility appeared to be free of vermin LPA observed no citations during the physical plant inspection. There are currently no staff or client files to review. Exit interview conducted and documentation provided to Ms. Edwards.

report_type: Facility Evaluation

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an announced annual inspection on 2/7/23 at 9: AM and met with Tracy Edwards, Administrator, to conduct the inspection. LPA Hill toured the facility inside. LPA Hill did not tour the outside of the facility due to the volume of snow surrounding the building. LPA Hill observed that the facility is currently not occupied and there are no clients in care at this time. LPA observed that the smoke detectors were functioning as required and that there is a carbon monoxide detector on the second level of the home. LPA Hill observed that the fire extinguishers were last serviced on 2/2/23 and there is one on the first floor near the kitchen and the other is upstairs at the top of the stairs. LPA Hill observed that the mental health certificate is on display at the front door and is current for year 2022 to 2023. At this time, this facility does not have any clients in care. LPA Hill observed that the facility is ready for clients should the need arise. LPA Hill observed that the bedrooms are equipped with appropriate furnishing and that beds are made and ready for clients. LPA Hill observed that the water is within the required temperature. LPA Hill observed that there is no food at the house - perishable or nonperishable due to there being no clients in care. The freezer and refrigerator are unplugged at this time due to them not being in use. LPA Hill advised the facility that if clients are placed in the facility that the administrator notify licensing so that we are aware that clients are no occupying the facility. There were no citations issued during the inspection today and exit interview was conducted with Ms. Edwards. Documentation was provided at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced collateral inspection to the agency's administrative office in Minden, Nevada and met with Tracy Edwards, Program Director, on 6/6/23 at 12: PM. LPA Hill informed Ms. Edwards that the purpose of the inspection was to discuss a program design addendum regarding overnight staffing that was sent to LPA Hill on 5/28/23. The addendum from the agency outlines that this facility will not have an awake night staff person but would have a staff person present at the facility sleeping while the three youth sleep. LPA Hill informed Ms. Edwards that the regulations for Short Term Residential Therapeutic Programs (STRTP) Interim Licensing Standards (ILS) requires "During the hours of 10 pm to 7 am, there shall be one awake and on duty direct care staff for every six children, or fraction thereof, present, at a minimum. [86065.5]" This means that the Department cannot accept this addendum and the facility shall provide the awake night staff as required. Further discussing, Ms. Edwards requested an exception for the three youth currently present in the facility to not have the awake night staff as required as the youth have completed their requirements as STRTP clients and are awaiting AB 12 transition and/or transitional housing acceptance. LPA Hill informed Ms. Edwards that an exception would need to be in writing and submitted to the Department for review/approval. LPA Hill informed Ms. Edwards that if they would like to proceed, they can submit the required written documentation to the Department for review. Ms. Edwards stated that she would work on the necessary paperwork this week to get it to the Department for review. End of inspection.

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an announced annual inspection on 12/22/23 at 9: AM and met with Tracy Edwards, Administrator. LPA Hill conducted an announced inspection as the facility is currently not operating and does not currently have clients in care or staff. This facility currently does not have an administrator as the named administrator has been redirected to programs outside the state of California. The agency will not populate the home or operate this location until a qualified administrator can be hired and trained. LPA Hill conducted the physical plant inspection of the facility and observed that the facility is a split level home with two client rooms upstairs and one client room downstairs. There are two client bathrooms in the facility and that there was hot water in all faucets and sinks. There is currently no food in the house as the facility is not sure when they will be able to fill the home as they are still recruiting for an administrator and Head of Service for this house. LPA Hill observed that the carbon monoxide detector and smoke alarms are all working as required. LPA Hill observed a fire extinguisher that was last inspected in November 2022. LPA Hill observed that the facility meets all requirements according to the Interim Licensing Standards and there were no citations observed during the inspection. Exit interview conducted with Ms. Edwards and document provided.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced annual inspection on 12/10/24 at 9: AM and met with Tracy Edwards, Program Administrator, to conduct the physical plant inspection of the facility as part of the annual inspection. LPA Hill observed that the facility has three dual occupancy bedrooms upstairs, one downstairs and two upstairs, for clients in care, but there are currently no youth in care at this time. LPA Hill observed that the facility was clean, safe and sanitary during the annual inspection. LPA Hill observed that the smoke detectors and carbon monoxide detectors were functioning as required. Fire extinguishers were last inspected 1/23/24. LPA Hill observed one client restroom upstairs that had running hot water, paper towels, a flushing toilet, and a shower that delivered hot water. The other restroom is downstairs and also has hot water, paper towels, flushing toilet, and a shower that delivers hot water. LPA Hill observed that the client bedrooms were supplied with proper bedding including mattress cover, fitted sheets, blankets, pillows, closet space, and storage for belongings. LPA Hill observed that the facility did not have the required perishable or non perishable food supply as there were no clients in care at this time. LPA Hill observed that the facility did have the appropriate cook ware and dining supplies and can make ready this facility for clients should there be a need. LPA Hill observed that the facility was safe for youth, inside and out, if needed for client placement. No interviews were conducted for staff or clients as there are no clients in care. End of inspection. Document was provided to Ms. Edwards and exit interview was conducted.

met_with: Tracy Edwards, Program Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill conducted a case management inspection at the agency's administrative office on 6/26/25 at 11: AM and met with Tracy Edwards, Administrator to discuss an incident report dated 6/18/25. The incident report details that C1 received a probation visit on 6/18/25 where C1 was drug tested by the probation officer. C1 tested positive for a substance(s) that are prohibited which prompted the probation officer to then search C1's bedroom, finding another prohibited item(s). As a result of the drug test and contraband found in C1's possession, C2 and C3 were also tested and their rooms searched. When discussing this incident with Ms. Edwards, LPA Hill advised the agency to be careful as this may be perceived as an unnecessary search of C2 and C3's persons simply because they share the house with C1. LPA Hill advised that there did not seem to be any behavior(s) that prompted C2 or C3 to be tested or their rooms searched nor was it documented that approval from their placing agency was obtained prior to conducting said drug testing or rooms search(es). Ms. Edwards stated that permission was obtained from the placing agencies for C2 and C3, for the drug testing and the room searches, but did not document it on the incident report. In addition to this, it is noted on the incident report that the agency will "continue to randomly drug test all three [youth]". LPA Hill advised that without a court order explicitly stating that random drug testing is required, the agency cannot do this. LPA Hill stressed that this must be by court order and not as ordered by the youths' probation officers. LPA Hill did provide the agency with an Advisory Note - Technical Violation related to Personal Rights and unreasonable searches. Exit interview conducted and documents provided.


facility_name: RUBICON RANCH

summary: Facility Evaluation

raw_content:
Narrative:
On Friday, December 19th, 2025 at 10AM, Licensing Program Analyst (LPA) Brittany Crass and Licensing Program Manager (LPM) Tamara Hill, met with applicant Alexis Thrasher at the Community Care Licensing office for a Component II meeting. LPA discussed Administrator Qualifications, receipt of Sacramento County letter, Facility Sketch, Training, Removal Procedures, Personal Rights, Medications, Mental Health Approval, and more. LPA discussed needing all required forms for the corporation such as Board of Directors, LIC 309, and others. During the meeting, licensing documents were reviewed and requested they be updated. Component III will be scheduled in January 2026. Date and location to be determined by email. Exit interview conducted with Applicant, Alexis Thrasher and a copy of this report was provided.

met_with: Alexis Thrasher


raw_content:
Investigation Findings:
13On 10-6-22 9: AM Licensing Program Analysts Karkazis conducted a complaint investigation with REFUGE and met with Sylvia Smith, Administrator. The purpose of this inspection was to deliver the findings for the above complaint allegations. The complaint was taken by Community Care Licensing's (CCL's) Investigative Branch (IB)and assigned to investigator Megan Mullen. During the investigation, it was discovered that the alleged staff member had an argument with the client. During the investigation, through document research and confidential interviews with staff and clients, no one made any disclosures regarding observing firearms in the facility or staff talking about firearms. Child and Family Services (CFS) conducted an investigation and were provided with conflicting information.. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that staff threatened a minor with a firearm while in care. Therefore, the above allegation is UNSUBSTATIATED. An exit interview was conducted, and a copy of this report was given to Sylvia Smith, Administrator. 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: Sylvia Smith Administrator


raw_content:
Narrative:
continued from LIC An exit interview was conducted and a copy of this report was given to Dwayne White, Facility Administrator.

Investigation Findings:
13On 1-6-23 2:57PM, Licensing Program Analyst (LPA) George Karkazis conducted an unannounced follow up inspection at the REFUGE I, and met with Dwayne White, Facility Administrator. The purpose of the inspection was to deliver the findings for the above complaint allegation. Regarding the allegation of staff yelling at minors: During the course of the investigation, LPA Karkazis conducted confidential interviews and documentation research. There was no evidence of staff yelling at minors in document research. Staff and clients interviewed stated that they have never heard staff yelling at clients in a derogatory manner. S1 stated that she speaks in a loud tone regularly and may raise her voice occasionally if clients cannot hear her. LPA interviewed residents of neighboring homes, stated that they have never heard staff yelling at minors. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that staff are yelling at minors. Therefore, the allegation is UNSUBSTANTIATED. continued on LIC 9099-C 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 Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CENTRAL COAST SC/RES, TRAEGER AVE., Suite San Bruno, CA Facility Name: R.E.F.U.G.E.FACILITY NUMBER: VISIT DATE: 01/06/2023

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

met_with: Dwayne White, Facility Administrator


raw_content:
Narrative:
continued from LIC Appeal Rights were provided and discussed with the facility, and deficiencies were cited. The facility was cited for Health and Safety Code 1568. Conduct Inimical. At this time, the case is being reviewed for enhanced civil penalties. An exit interview was conducted and a copy of this report was given to Dwayne White, Facility Manager.

Investigation Findings:
13On 3-1-23 3:35PM, Licensing Program Analyst (LPA) George Karkazis made an unannounced inspection to REFUGE and met with Dwayne White, Facility Manager. The purpose of the inspection was to deliver the findings for the above allegation. The investigation was conducted by Community Care Licensing (CCL) Investigation Branch (IB), Investigator Jorge Martinez. During the course of the investigation, (IB) conducted interviews with staff members, clients, witnesses, and authorized representatives. Based on confidential interviews by (IB), (S1) (see LIC 811 confidential names dated 9-27-22) sexually assaulted (C3) on three separate occasions, that occurred in a location outside of the facility. Based on the information obtained, there is a preponderance of the evidence to prove that staff had a sexual relationship with a foster child. Therefore, the above allegation is SUBSTANTIATED. continued on LIC 9099-C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego 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 Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CENTRAL COAST SC/RES, TRAEGER AVE., Suite San Bruno, CA Facility Name: R.E.F.U.G.E.FACILITY NUMBER: VISIT DATE: 03/01/2023

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

met_with: Dwayne White, Facility Manager


raw_content:
Narrative:
The allegations that staff are performing inappropriate searches on minors while in care. may or may not be true. The allegations have not met the preponderance of doubt and are therefore unsubstantiated. No deficiencies were cited at this time. LPA conducted an exit interview with Administrator, Mr. White, at 1: PM.

Investigation Findings:
13On 06/5/2023 at 10:00AM, Licensing Program Analyst (LPA) Vaishali Singh-Sood conducted a visit to the above agency to deliver the findings on the listed allegation. LPA met with Administrator, Mr. White. At the time of the visit, there were 2 staff, and 2 clients present in the facility. During the course the investigation, LPA conducted confidential interviews with reporting party member, clients, social workers, and resource parents. According to confidential interviews, records reviews, and a walkthrough of the facility, LPA Singh-Sood concluded, the allegation had inconsistent support. 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, and no Title 22 deficiencies were observed. (Continued on LIC 9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Vaishali Singh-Sood LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: R.E.F.U.G.E.FACILITY NUMBER: VISIT DATE: 06/06/2023

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

met_with: Dwayne White


raw_content:
Narrative:
The allegations that staff inappropriately handled a child in care and staff inappropriately pushed on a child to fall down the stairs. may or may not be true. The allegations have not met the preponderance of doubt and are therefore unsubstantiated. No deficiencies were cited at this time. LPA conducted an exit interview with Administrator, Mr. White, at 1: PM.

Investigation Findings:
13On 06/5/2023 at 10:00AM, Licensing Program Analyst (LPA) Vaishali Singh-Sood conducted a visit to the above agency to deliver the findings on the listed allegation. LPA met with Administrator, Mr. White. At the time of the visit, there were 2 staff, and 2 clients present in the facility. During the course the investigation, LPA conducted confidential interviews with reporting party member, clients, social workers, and resource parents. According to confidential interviews, records review, and a walkthrough of the facility, LPA Singh-Sood concluded, the allegation had inconsistent support. It is further noted the client involved in the allegations refused to return a callback to this LPA. 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, and no Title 22 deficiencies were observed. (Continued on LIC 9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Vaishali Singh-Sood LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: R.E.F.U.G.E.FACILITY NUMBER: VISIT DATE: 06/06/2023

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


raw_content:
Investigation Findings:
13On 10-27-23 11:47, Licensing Program Analyst (LPA) Karkazis conducted an unannounced inspection at REFUGE and met with Arireisea Adanandus, Facility Manager, who helped with the inspection. The purpose of the inspection was to deliver the complaint findings. The complaint alleged that staff handled a foster child in a rough manner, staff do not accord foster child with dignity and respect, staff leave tools accessible to foster children, staff leave cleaning supplies accessible to foster children, and facility is in disrepair. Licensing Program Analyst (LPA) Karkazis conducted confidential interviews with staff, clients, representatives, and conducted document research, in which inconsistent information was provided. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegations occurred. Therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was given to Arireisea Adanandus, Facility Manager. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lidia Tinoco 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: Arireisea Adanandus, Facility Manager


raw_content:
Investigation Findings:
13On 1-31-24 1:49PM, Licensing Program Analyst (LPA) George Karkazis conducted an unannounced inspection at REFUGE 1, and met with Dwayne White, Administrator, who helped with the inspection. The purpose of the inspection was to deliver the complaint findings. The complaint alleged that staff did not prevent minors from stealing other minor's personal belongings and staff did not adequately supervise minor resulting in minor leaving the facility. LPA Karkazis conducted confidential interviews and document research, in which inconsistent information was provided. LPA could not locate the victim/client for their statement. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the allegations occurred. Therefore, the allegations are UNSUBSTANTIATED. A copy of this report was given to Dwayne White, Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego 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 1

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

met_with: Dwayne White, Administrator


summary: Facility Evaluation - 2 deficiencies

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Narrative:
Licensing Program Analyst (LPA) Christopher Rollins made an unannounced annual required inspection to REFUGE Short Term Residential Therapeutic Program (STRTP). LPA met with Sylvia Smith Administrator, Geneva Morgan Facility Manager and Jason Henderson Director. The STRTP is licensed to served 6 clients ages 13-17. The facility consists of three bedrooms (3 for clients) and Bathrooms. The facility is a one story home with a side office. The facility is licensed for 6 residents and currently 4 clients reside in facility. No more than two clients share a bedroom. At 11: AM, LPA, Administrator and FM conducted a walk through of the facility and office. LPA observed the kitchen to be clean. The hot water in the bathroom, shower and kitchen measured 110 degrees F which is currently between 105 - 120 degrees. The facility has plenty of nonperishable and perishable food supply. Medication, knives and cleaning supplies is locked away. There are enough folks, spoons, plates and cups. All passageways are unobstructed. All smoke detectors are update and working. The home is clean, safe, and sanitary. There are no firearms on the property. The fire extinguisher has been checked and is up to date. There are no bodies of water on the property. The home is maintained at a comfortable temperature. Personal rights, floor plan, food menu and Emergency disaster forms were posted and in clear view. At 12: PM, LPA reviewed four clients files with Administrator, FM and Director. LPA observed all four clients files to be missing Authorized Representative signatures for Needs and Services Plans, Medical Consent Form and clients' personal rights documents. LPA also observed that all four clients TB Test, Immunization Records and Medical Assessment form were not up to date. At 1: PM, LPA reviewed six staff files with Administrator, FM and Director. LPA observed all six staff files to be complete and found no deficiencies. LPA observed all staff files to have the correct up to date documentation and all staff were up to date with their staff training for the year. Per Title Regulations and Interim Licensing Standards regulations were cited and exit interview was conducted. A Copy of the report and deficiencies were left at the facility.

Deficiencies:
87068.3(a): Modifications to The Needs And Services Plan

(a) The needs and services plan specified in Section 87068.2 shall be updated at least every 30 days to determine the following
87068.2: (2)

met_with: Sylvia Smith-Administrator, Geneva Morgan- Program Manager and Jason Henderson-Director


summary: Facility Evaluation

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Narrative:
On Wednesday, May 6th 2026, a scheduled office meeting was held with the licensee. The purpose of the meeting was to discuss the licensee's placement arrangements with Alameda County. In attendance representing the licensee was Executive Director Jason Henderson. Representing the licensing agency were Assistant Program Administrator (APA) Margo Castaneda, Regional Manager (RM) Helga Wong, Licensing Program Manager (LPM) Isabel Diego, LPM Carolyn Flynn, and Licensing Program Analyst (LPA) Mariah Hawkins. Representing Alameda County was Mia Buckner-Preston, Division Director for Resource Family Approval & ILP Support Services in the Alameda County Department of Children & Family Services. The following items were discussed during the meeting: Plan of Operation Counties licensee accepts placements from Served population for each of licensee's children's facilities Mental health services Staff training Administrator designations A copy of this report was provided via email to Executive Director, who agreed to return a signed copy to LPA Mariah Hawkins.

met_with: Executive Director Jason Henderson


summary: Facility Evaluation

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Narrative:
On May 20th 2026, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit. LPA met with Administrator Dwayne White and Program Director Marla Anderson and informed of the purpose of the visit. The purpose of the visit was to conduct an interview. LPA conducted one confidential interview. During the visit, LPA observed minor damage to the facility vehicle. LPA discussed this with Administrator. See LIC 9102 attached. An exit interview was conducted, and a copy of this report was provided to Administrator.

met_with: Administrator Dwayne White; Program Director Marla Anderson


summary: Complaint Investigation - Unsubstantiated

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Investigation Findings:
13Licensing Program Analyst (LPA) Christopher Rollins conducted a tele-visit follow-up complaint inspection with REFUGE II and spoke with Sylvia Smith Administrator. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the course of investigating these allegations, LPA Rollins conducted confidential interviews with staff, clients, support staff, Social Worker, received documentation and conducted client file review. Confidential interviews reveal conflicting stories on if facility staff abandoned client in care. Confidential Interviews reveal conflicting stories on if facility staff failed to meet clients in care needs. Based on interviews and documentation there was not enough evidence to prove that facility staff abandoned client in care and facility staff failed to meet clients in care needs. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that facility staff abandoned client in care and facility staff failed to meet clients in care needs, therefore the above allegation is unsubstantiated. Exit interview conducted with Adminstrator and report was e-mail to Administrator for signature. 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 1

met_with: Sylvia Smith-Administrator


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Christopher Rollins conducted a tele-visit follow-up complaint inspection with REFUGE II and spoke with Sylvia Smith Administrator. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the course of investigating these allegations, LPA Rollins conducted confidential interviews with staff, clients, support staff, Social Worker, received documentation and conducted client file review. Confidential interviews reveal conflicting stories on if client in care sustained unexplained injuries while in care. Based on interviews and documentation there was not enough evidence to prove that client in care sustained unexplained injuries while in care. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that client in care sustained unexplained injuries while in care, therefore the above allegation is unsubstantiated. Exit interview conducted with Adminstrator and report was e-mail to Administrator for signature. 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


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Investigation Findings:
13Licensing Program Analyst (LPA) Christopher Rollins conducted a follow-up complaint inspection at REFUGE II and met with Sylvia Smith Administrator. The purpose of the inspection was to deliver the finding for the above complaint allegation. During the course of investigating the allegation, Investigator conducted confidential interviews with staff, clients, support staff, Social Worker, received documentation and conducted client file review. Confidential interviews reveal conflicting stories about client in care being inappropriately touch by an unknown person. Based on interviews and documentation there was not enough evidence to prove that client in care was touched inappropriately by an unknown person. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that client in care was touched inappropriately by an unknown person, therefore the above allegation is unsubstantiated. Exit interview conducted with Adminstrator and report was left 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


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Investigation Findings:
13On 1/3/23 at 1: PM, Licensing Program Analyst (LPA) Alyssa Ng conducted a complaint inspection at R.E.F.U.G.E II and spoke Laurie Taylor, Facility Manager. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the investigation, LPA Ng reviewed documents and conducted interviews with client and staff. All interviewed parties stated that no staff treated minor differently from other minors in care, yell at minor, withheld water, snacks, or medication. During a review of client files, all medication prescribed to clients match the medication book. In addition to the client files, LPA also reviewed facility shift notes and found that client refused medication various times. Although, the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that staff withheld medication from minor, staff yells at minor, staff not allowing minor to drink water, and staff not treating minor equal to the other minors in care. Therefore, the above allegations are unsubstantiated. Exit interview was conducted and a copy of the report was left with Laurie Taylor, Facility Manager. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Alyssa Ng LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

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

met_with: Laurie Taylor


raw_content:
Investigation Findings:
13On 9/25/2023 at 11:00AM, Licensing Program Analyst (LPA) Lisette Valenzuela conducted a visit to the above agency to deliver the findings on the listed allegation. LPA Valenzuela met with Sylvia Smith, Acting Administrator. During the course of the investigation, LPA Valenzuela conducted confidential interviews, and reviewed records. Based on confidential interviews, record review and observations the preponderance of evidence standard has been met, the allegation, "Staff do not report incidents to appropriate parties", is substantiated. Title 22, Version 6, - 80061 (b) Reporting Requirement, is being cited on the attached LIC9099-D. Exit interview was conducted and a copy of this report was printed and left with Sylvia Smith. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Lisette Valenzuela LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, This is an official report of an unannounced visit/investigation of a complaint received in our office on 06/08/2023 and conducted by Evaluator Lisette Valenzuela PUBLICCOMPLAINT CONTROL NUMBER: 14-CR- FACILITY NAME:R.E.F.U.G.E.IIFACILITY NUMBER: ADMINISTRATOR:GEORGE JORDON IIFACILITY TYPE: ADDRESS: GARDEN STREETTELEPHONE: (510) 533- CITY:OAKLANDSTATE: CAZIP CODE: CAPACITY:6CENSUS: DATE: 09/25/ UNANNOUNCEDTIME BEGAN: 11: AM MET WITH:Sylvia SmithTIME COMPLETED:12: PM 9Staff do not properly supervise minor. Staff did not assist minor with obtaining medical care. INVESTIGATION FINDINGS: 13On 09/25/2023 at 11:00AM, Licensing Program Analyst (LPA) Lisette Valenzuela conducted a visit to the above agency to deliver the findings on the listed allegations. LPA met with Sylvia Smith, Director. During the course the investigation, LPA conducted confidential interviews with reporting party member, clients, and staff members. According to confidential interviews, and record review, LPA Valenzuela concluded, the allegations that, "Staff do not properly supervise minor" and "Staff did not assist minor with obtaining medical care", had inconsistent support. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated, and no Title 22 deficiencies were observed. Exit interview was conducted and a copy of this report was left with Sylvia Smith, Director. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Lisette Valenzuela LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 2 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: R.E.F.U.G.E.IIFACILITY NUMBER: 015600744

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: Sylvia Smith


raw_content:
Investigation Findings:
13On 9/25/2023 at 11:00AM, Licensing Program Analyst (LPA) Lisette Valenzuela conducted a visit to the above agency to deliver the findings on the listed allegation. LPA Valenzuela met with Sylvia Smith, Acting Administrator. During the course of the investigation, LPA Valenzuela conducted confidential interviews, and reviewed records. Based on confidential interviews, and observations the preponderance of evidence standard has been met, the allegation, "Staff are locking the food up so minor cannot eat", is substantiated. Interim Licensing Standards STRTP Version 4, - 87072 (c) (11) Personal Rights, is being cited on the attached LIC9099-D. Exit interview was conducted and a copy of this report was printed and left with Sylvia Smith. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Carolyn Flynn LICENSING EVALUATOR NAME: Lisette Valenzuela LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: R.E.F.U.G.E.IIFACILITY NUMBER: 015600744

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


raw_content:
Investigation Findings:
13On 12-5-23 3:40PM, Licensing Program Analyst (LPA) George Karkazis conducted an unannounced inspection at REFUGE II, and met with Dwayne White, Administrator, who helped with the inspection. The purpose of the inspection was to deliver the complaint findings. The complaint alleged that staff used inappropriate language towards a minor. LPA Karkazis conducted confidential interviews, document research, and obtained video of the incident. The information obtained from interviews indicates that staff used inappropriate language towards the minor. LPA Karkazis observed the video of staff yelling, taunting, and using inappropriate language towards a minor. Based on the information obtained, there is a preponderance of evidence to prove the above allegation is SUBSTANTIATED. The facility is being cited for Interim Licensing Standards, Article 6, Continuing Requirements, Personal Rights 87072(c)(16), Type A. An exit interview was conducted, appeal rights provided, and a copy of this report was given to Dwayne White, Administrator. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lidia Tinoco 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 Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., Suite San Bruno, CA Facility Name: R.E.F.U.G.E.IIFACILITY NUMBER: 015600744

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:
continued from LIC The facility is being cited for Interim Licensing Standards Article Continuing Requirements 87061(b)(4) and Title 22, Division 6, Chapter 1, Article 6, Continuing Requirements 80061(b)(1)(E). An exit interview was conducted, Appeal Rights provided and a copy of this report was given to Melvin Mahon, Administrator.

Investigation Findings:
13On 1-12-24 10:07AM, Licensing Program Analyst (LPA) George Karkazis conducted an unannounced inspection at REFUGE II, and met with Melvin Mahon, Administrator, who helped with the inspection. The purpose of the inspection was to deliver the complaint findings. The complaint alleged staff did not report youth missing in a timely manner. LPA conducted confidential interviews with client authorized representatives and stated that the facility did not inform them when the client was on AWOL multiple times. The complaint also alleged staff are not following reporting requirements. LPA conducted document research and found the client had AWOLed nine times in October 2023, for multiple days at time. Only three incident reports were turned in by the facility to CDSS in October 2023. . Based on the information obtained, there is a preponderance of evidence to prove that staff did not report youth missing in a timely manner and staff are not following reporting requirements. Therefore, the allegations are SUBSTANTIATED. continued on LIC 812-C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lidia Tinoco 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 Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., Suite San Bruno, CA Facility Name: R.E.F.U.G.E.IIFACILITY NUMBER: VISIT DATE: 01/12/2024

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: Melvin Mahon, Administrator


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

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Investigation Findings:
13Licensing Program Analyst (LPA) Christopher Rollins conducted a follow-up complaint inspection at REFUGE III and spoke with Khea Gumbs Administrator. 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 inappropriately touch client in care. Based on interviews and documentation there was not enough evidence to prove that facility staff inappriately touch 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 inappropriately touch client in care,therefore the above allegation is unsubstantiated. Exit interview conducted with Adminstrator and report was e-mail to Administrator for signature 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: Khea Gumbs-Administrator


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Christopher Rollins conducted a follow-up complaint inspection at REFUGE III and spoke with Khea Gumbs Administrator. The purpose of the inspection was to deliver the finding for the above complaint allegations. 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 handled client in care in a rough manner and facility staff used inappropriate form of discipline. Based on interviews and documentation there was not enough evidence to prove that facility staff handled client in care in a rough manner and facility staff used inappropriate form of discipline. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that facility staff handled client in care in a rough manner and facility staff used inappropriate form of discipline,therefore the above allegation is unsubstantiated. Exit interview conducted with Adminstrator and report was e-mail to Administrator for signature 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


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Christopher Rollins conducted a follow-up complaint inspection at REFUGE III and spoke with Khea Gumbs Administrator. The purpose of the inspection was to deliver the finding for the above complaint allegations. 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 locked client in care out of the facility and facility staff handled client in care in a rough manner. Based on interviews and documentation there was not enough evidence to prove facility staff locked client in care out of the facility and facility staff handled client in care in a rough manner. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that facility staff locked client in care out of the facility and facility staff handled client in care in a rough manner,therefore the above allegation is unsubstantiated. Exit interview conducted with Adminstrator and report was e-mail to Administrator for signature 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


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Christopher Rollins conducted a follow-up complaint inspection at REFUGE III and spoke with Khea Gumbs Administrator. 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 caused injury to client in care. Based on interviews and documentation there was not enough evidence to prove that facility staff caused injury to 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 caused injury to client in care,therefore the above allegation is unsubstantiated. Exit interview conducted with Adminstrator and report was e-mail to Administrator for signature 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