raw_content:
Narrative:
Confidential interviews were conducted with eleven individuals and attempted with one individual during the period of 11/21/2022 to 06/23/2023. Multiple statements gathered during interviews were consistent that grocery and household items are purchased and stocked in the facility, and that food is of good quality, however documentation reviewed were inconsistent regarding the quality of food being served to clients in care. Receipts were requested for purchases made during the months of September 2022 to December 2022 pertaining to groceries and household item purchases, allowance/gift card purchases, and costs and purchases made for repairs. The facility provided the Department with a total of three receipts, for months September, October and December 2022. One of three receipts provided to the Department included a purchase for alcohol. Copies of meal menus were requested for all weeks included in the months September 2022 - December 2022 and the facility provided the Department with a meal menu for the week of December 26, 2022 - January 1, 2023. The facility was unable to provide additional requested documentation to the Department regarding food service compliance, and LPA was unable to determine if the required amounts of food were purchased by the licensee for the total number of clients in care. Additionally, a Solvency Audit was conducted and finalized on June 07, 2023 by Jacqueline Juarez, Auditor, which indicated that the licensee is making sufficient income to meet operating expenses; however, funds are not being managed to ensure solvency. This was evident based on information gathered regarding the licensee accessing a local Food Bank for food items for clients in care. Based on interviews provided and documentation review, including two invoices for the Food Bank, LPA could not determine the quality of food or how the food items are selected, stored, prepared and served. Three additional grocery receipts submitted to the Department showed the licensee utilized a community membership club to obtain groceries for the youth in care as well and it is unclear why the licensee utilizes the Food Bank. Based on interviews conducted and LPA's review of documentation, along with the findings of the Department's Solvency Audit, the Department was unable to determine that the licensee is in full compliance with the food service requirements set forth in Title 22 regulations. continued on 9099-c USDA Guidelines for ages 14-19 averaged for male and female, amount for December 2022 is $277.10 per person. The total amount to be spent for eight clients is $2,216.80. The amount calculated from bank statements and food bank receipts totaled $323.07. Licensee's total amount spent equated to $40.38 per client. The Licensee underspent on food provisions by <$1,893.73>. Based on LPA observations, documentation reviewed, and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. The facility is being issued one citation for deficiencies related to CCR Title Regulations, section 80076(a), Food Services. An exit interview was conducted, and a signed copy of this LIC-9099 report, LIC-9099D and the Appeal Rights were provided to the facility. LPA's observation, interviews conducted, and records reviewed were inconsistent that staff are not providing adequate supervision. Upon review of the Staff Roster and Staff schedule show an adequate number of staff employed by the facility. Statements given during interviews regarding staff's level of supervision of clients in care were consistent that multiple staff are present in the facility and supervise the clients in care, as well as conduct periodic room checks when clients are in their bedrooms. However, levels of supervision were stated to vary between clients in care based on if a client exhibits unsafe behavior. For clients who exhibit unsafe behaviors, staff may increase the number of staff present or increase the frequency of supervision and/or room checks for specific clients. Based on LPA interviews conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. 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. An exit interview was conducted, and a copy of this report was provided to Raynisha McDonald, Administrator.

Investigation Findings:
13Licensing Program Analyst (LPA) Stephannie Verna conducted an unannounced complaint inspection with the above facility on June 28, 2023 and met with LPA Verna met with Joe Marrable, Program Director in-person, and with Licensee, Raynisha McDonald, by phone. The purpose of the inspection was to deliver complaint findings for the above allegation(s). The current census is seven youth in care. On 12/09/22, Licensing Program Analysts (LPA) Jessica Caplinger initiated the complaint investigation and met with Raynisha McDonald, facility licensee. LPA conducted an inspection of the facility, and gathered documents related to the complaint. During the course of the investigation, the following documents were gathered and reviewed: Youth Roster, Staff Roster, Receipts, Billing Statements, Loan Documents, LIC Monthly Operating Statement for December 2022, LIC Balance Sheet for December 2022, Repair Invoices/Grocery Receipts, Needs and Services Plans, Meal Menu, Staff Shift Reports, Law Enforcement Reports and Incident Reports and facility Program Statement. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Stephannie Verna 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 NO. Cal Cr/res., Natomas Park Dr., Ste Sacramento, CA Facility Name: Circle C Ranch INC.FACILITY NUMBER: VISIT DATE: 06/28/2023

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:

Deficiencies:
80076(a): Food Services
(a) In facilities providing meals to clients, the following shall apply


state: CA

facility_name: CIRCLE C RANCH INC.

summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On December 27, 2021 at 12: PM, Licensing Program Analyst (LPA) Stephannie Verna arrived at the above facility to conduct an unannounced annual/required inspection of the facility. LPA Verna met with Angela Duhart, Assistant Administrator. The facility is a STRTP facility, and offers care and supervision, and services, to six youth. LPA began the annual/required inspection on today's date. LPA began the client file review and reviewed a total of six client files. LPA will continue the client file and medication review on another date. Upon review of the six client files, LPA observed that: There were a total of three out of six client files that did not contain Immunization Records; Three out of six client files did not contain documentation of a medical assessment. One of six client files contained documentation of an untimely medical assessment; Three out of six client files did not contain TB test results or documentation that a TB test was administered. One out of six client files contained documentation that a TB test was taken, but test was taken untimely and there are no test results. One out of six client files contained an untimely TB test result; and Six out of six client files contained quarterly Needs and Services Plans. The NSPs are not being completed every 30 days. Additionally, there were some missing intake documents in some of the client files, while the other client files had the completed and signed intake documents; The facility is not documenting conversations pertaining to the assessment for compatibility of youth to share bedrooms. There are four out of six clients who share a bedroom, and do not have this documentation; Six out of six client files did not contain education goals on the Needs and Services Plans, Money Management, and Visitation or restrictions to visits, and are not individualized NSPs; The initial medical assessment does not include the ambulatory status of the clients; and Six out of six client files did not contain education goals on the Needs and Services Plans, Money Management, and Visitation or restrictions to visits, and are not individualized NSPs. The facility annual/required inspection is to be completed on another date. The facility is being cited for deficiencies to Interim Licensing Standards, STRTP, section 87070(c)(3); Interim Licensing Standards, STRTP, section 87068.3(a); California Code of Regulations, Title 22, chapter 1, section 80069(c)(1); and California Code of Regulations, Title 22, chapter 1, section 80069(c)(1). See 809-Ds and Plan of Correction for additional information. LPA Verna completed an exit interview with Angela Duhart, Assistant Administrator, and Raynisha McDonald, Administrator. A copy of this report and appeal rights was provided to Angela Duhart, Assistant Administrator, and Raynisha McDonald, Administrator.

Deficiencies:
87068.3(a): (a) The needs and services plan specified in Section 87068.2 shall be updated at least every 30 days to determine the following

report_type: Facility Evaluation

visit_type: Annual

met_with: Angela Duhart, Assistant Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On December 28, 2021 at 10: AM, Licensing Program Analyst (LPA) Stephannie Verna arrived at the above facility to conduct an unannounced annual/required inspection of the facility. LPA Verna met with Angela Duhart, Assistant Administrator. LPA continued the annual/required inspection on today's date. LPA conducted four client interviews. One client refused to interview, and one client was not present. LPA completed four staff interviews. LPA reviewed the facility's emergency intervention, disaster preparedness plan, and plan of operations and found that the facility had all required pertaining documentation completed with the exception of disaster drill logs. The Administrator stated that a new drill binder was created after the old binder was destroyed. The facility stated that they conduct monthly drills, but current documentation for 2021 was not located or provided. LPA continued the review of client files, client medications and logs, and LPA observed that: One out of six client files did not contain the JV-220. The facility does not utilize or maintain a register of clients, containing the current necessary information; and Six out of six client files did not contain a standard appraisal form. The pool is located indoors in a covered sun room. The pool area was free of hazards, and the sliding door to the home was equipt with an audible alarm, which sounded non-stop when the door would open. The facility had weekly meal menus posted, and had healthy and available food options for youth to chose from. More than one week of non-perishable foods and two days of perishable foods were observed to be present in the facility fridge and pantry. Sharps and hazardous chemicals and cleaners were locked in the facility. The facility had necessary first aid supplies. Medications were stored in a locked closet and locked containers. During the visual inspection, LPA observed that: The hot water was tested at multiple sources and measured at 150 degrees F. The staff lowered the water heater setting and the water temperature will be tested again. One out of two carbon monoxide detectors (upstairs) was inoperable. The annual inspection was completed and finalized on today's date. The facility is being cited for deficiencies to the following regulations: Interim Licensing Standards (ILS) regulations, section 87070(b)(11); California Code of Regulations, Title 22, section 80088(e)(1); California Code of Regulations, Title 22, section 80023(d)(2); ILS regulations, section 87095.65(d)(1); California Code of Regulations, Title 22 section 80066(a)(12)(B); California Code of Regulations, Title 22, section 80066(a)(10); California Code of Regulations, Title 22, section 80066(a)(11); ILS regulations, section 87065.1(d)(7); ILS regulations, section 87065.1(c)(5); ILS regulations, section 87065.1(c)(6)(A); ILS section 87070(b)(15), and Health and Safety Code section 1503.2. See 809-Ds and Plan of Corrections for additional information. LPA Verna completed an exit interview with Angela Duhart, Assistant Administrator, and Raynisha McDonald, Administrator. A copy of this report and appeal rights was provided to Angela Duhart, Assistant Administrator, and Raynisha McDonald, Administrator. LPA Verna completed the staff file review, reviewing a total of ten staff files and observed that: Ten out of ten staff files did not contain training documentation for Emergency Intervention Staff Training; Six out of ten staff files did not contain documentation of the criminal record clearance or exemption received; Five out of ten staff files did not contain the LIC 198A, CACI check; The staff files did not contain staff evaluations; There is no signed documentation by STRTP staff regarding staff being over the age of 21 in the staff files; The personnel record was missing information including date of hire, and duties of the employee; Nine out of ten staff files did not contain a health screening report; Six out of ten staff files did not contain documentation of a TB test and its results; Multiple staff files reviewed did not contain education or experience information; Training assessments were not filed in ten out of ten staff files; Three out of ten staff files did not contain current CPR/First Aid completion certificates; and Documentation of training completed by staff was missing or incomplete in ten out of ten staff files. LPA Verna completed a visual inspection and walk-through of the facility. The facility sketch and license was posted in a prominent place. The facility is located in a rural location. LPA observed that the facility was clean, organized, and free of clutter. The facility is comprised of four bedrooms, two bathrooms, a kitchen and dining room, a living room, staff office, and a media/game room. The youth in care have ample space to conduct meetings with visitors, and complete homework or extracurricular activities. LPA tested and observed that the facility had working smoke detectors. One out of two carbon monoxide detectors (upstairs) was inoperable. LPA observed that the facility had multiple fire extinguishers, which were fully charged, and were serviced within the last year. The outside of the facility was free of potentially hazardous or dangerous items, and had ample space for outdoor activities. The facility had a large backyard and basketball court. There was a locked utility room for the pool pump and supplies, located outside.

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On December 21, 2022 at 1: PM, Licensing Program Analyst (LPA) Stephannie Verna arrived unannounced at the above facility for the purpose of a Plan of Correction (POC) visit related to two Type A citation issued on December 09, 2022 related to the facility being deficient in CCR Title 22 regulation section 80087(e) and CCR Title 22 regulation section 80019(e). During the inspection LPA observed that the swimming pool room, located outside the family room, had an installed alarm on the sliding door. Upon testing, the alarm on the sliding door to the pool area alerted and sounded continuously when the sliding door was opened. The alarm stopped when the door was closed. The sliding door was also locked. The doors in the swimming pool room were observed to be locked to/from the outdoors, leaving the pool inaccessible to clients in care. Multiple staff stated that the broken window in the pool area is scheduled to be replaced on 12/22/2022. The window company came out to replace it on 12/12/2022, however it was the wrong size window. LPA Verna inquired with Raynisha McDonald, facility licensee regarding background clearance documents for three staff S1, S2, S3) and was told since December 09, 2022 the three staff have not worked on shift while waiting for the staff's pending background checks to clear through Guardian. The POC related to CCR Title 22 regulation section 80087(e) and CCR Title 22 regulation section 80019(e) was cleared on today's date and POC clearance letters were issued to the facility. LPA will be informed by the facility once the three staff clear in Guardian. No citations were issued during the POC visit. A copy of this report was left with Raynisha McDonald, facility licensee.

met_with: Raynisha McDonald, facility licensee


facility_name: CIRCLE OF FRIENDS

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews revealed they do smoke marijuana outside the home. Other confidential interviews revealed they do smoke and when staff sees the clients smoking, staff tells them not to smoke, "but can't touch them." Confidential interviews stated that staff do room searches when they smell marijuana but never find their "stash." Confidential interviews revealed C5 did pull out a knife and threatened other residents. Confidential interviews revealed that staff were not aware C5 was in possession of a weapon and they had conducted room searches and never found the knife. In addition, confidential interviews disclosed C5 purchased the weapon when C5 was living in another foster home. Confidential interviews revealed that when C5 pulled out the knife S1 got in the middle of the altercation and used a piece of a vacuum to create space amongst the clients while S2 called law enforcement. Confidential interviews detailed that C5 had hidden the knife in their guitar which was in C5's possession at the beginning of C5's placement with Circle of Friends and staff did not think to check C5's guitar case for a weapon. Confidential interviews could not confirm or dispute that facility staff did not provide adequate supervision to minors in care. Based on confidential interviews and record review, although the allegations of C1, C2, C3, and C4 are smoking marijuana while in care, C1, C2, C3, and C4 threatened C5 while in care, C5 had access to a weapon while in care and staff do not provide adequate supervision to the minors while in care, may or may not have occurred, however it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report was provided along with appeal rights to Circle of Friends Program Director, Yoshita Conrad.

Investigation Findings:
13On October 8, 2021 at 2: PM, Licensing Program Analyst (LPA), Danielle Garcia, met with Facility Manager, Kai Pelaez, to deliver the findings for the above stated allegations. The investigation was conducted by Licensing Program Analyst (LPA) Danielle Garcia and LPA Marisol Lopez. During the investigation, LPA Garcia and LPA Lopez included interviews with Client 1(C1), Client 2 (C2), Client 3 (C3), Client 4 (C4), Client 5 (C5) refused interview, Staff 1 (S1), Staff 2 (S2) and Program Director (D1). In addition, Special Incident Reports, client records and facility records were reviewed. On August 18, Community Care Licensing received allegations of minors (C1, C2, C3, C4) are smoking marijuana while in care, (C1, C2, C3, C4) threatened C5 while in care, C5 had access to a weapon while in care and staff do not provide adequate supervision to the minors while in care. R- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, METROPOLITAN DR. # FACILITY NAME: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 10/08/2021

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

report_type: Complaint Investigation

met_with: Kai Pelaez

complaint_status: unsubstantiated


raw_content:
Narrative:
of this alleged incident makes residents in the facility feel uncomfortable and unable to trust staff. Confidential interviews were unable to confirm or dispute the abuse of former resident. Confidential interviews reported that there was a former staff member that was overly friendly with residents but denied that any inappropriate interactions were observed or occurred. Confidential interviews further reported current residents feel comfortable and safe in the facility and have at least one staff member they feel they can trust. Based on record review and confidential interviews the allegation of staff (unknown) sexually assaulted a minor (Child #2 [C2]) in care, may or may not have occurred, however it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of the report was provided along with appeal rights to Circle of Friends Administrator (ADM), Yoshita Conrad.

Investigation Findings:
13On December 16, 2021 at 9:05am Licensing Program Analyst (LPA), Nicole Strickland, met with Circle of Friends Administrator (ADM), Yoshita Conrad, to deliver the finding for the above stated allegation. LPA conducted an inspection of the facility on June 24, 2021 at approximately 1:50pm and no immediate deficiencies were observed. The investigation was conducted by Special Investigator Nikki Vo and LPA Strickland and included interviews with ADM, Staff #2 (S2), Staff #3 (S3), four of four foster children (Child #1 [C1], Child #2 [C2], Child #3 [C3], and Child #4 [C4]), and two County Social Workers (CSW#1, and CSW#2). One confidential witness did not respond to LPA's request for an interview and therefore was not interviewed. In addition, county records and facility records were reviewed. On June 18, 2021, Community Care Licensing (CCL) received an allegation alleging that staff (unknown) sexually assaulted a minor (Child #2 [C2]) in care. Specifically it was reported an unknown staff member abused a former resident prior to the resident leaving the facility. It was also reported that the knowledge UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Nicole Strickland LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 12/16/2021

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

met_with: Yoshita Conrad


raw_content:
Narrative:
On 06/03/2021, the Department received an allegation that due to a lack of staff supervision minor ingested pills resulting in death, client has access to weapons, client caused injury to another client in care, staff are not providing adequate supervision to clients, staff did not provide a safe environment to clients in care and staff did not report incidents. Confidential interviews stated the facility is limited to conducting searches and putting hands on the clients however the facility has taken measures to prevent the clients from entering the facility with alcohol and contraband by conducting routine checks. Confidential interviews stated staff were unaware that minor #1(M1) ingested street drugs prior to M1's shower and staff was unable to provide immediate first aide because it is underdetermined how long M1 was unresponsive prior to Paramedics and Fire Department arriving. Confidential interviews stated the facility has recently added additional staff to maintain continuous supervision of clients. Confidential interviews stated staff conduct room searches when it is suspected the individual client is in possession of an illegal substance, cigarettes, weapons, or belonging of others. Confidential interviews stated clients have been involved in physical altercations with each other however staff follow the emergency intervention plan and intervene to the best of their ability by placing their bodies between clients to de-escalate clients and law enforcement is contacted as a last resort however, the clients have rights and it would be a violation on the facility staff to search or place hands on clients or their personal belongings without the clients consent. Confidential interviews stated staff actively supervise and conduct 10-15 minute random night checks however when a client is AWOL, staff are unaware of clients behaviors or actions until they are reported by law enforcement or other. Confidential interviews stated all incidents that occur at the facility are reported to the appropriate parties including AWOL's. Confidential interviews stated during an AWOL attempt, staff follow the emergency intervention plan, staff follow client until staff lose sight of client, staff drive around looking for client, staff contact law enforcement and staff report AWOL's to appropriate parties. Confidential interviews stated staff meet with social workers and work with client to come up with behavioral contracts or incentives. Confidential interviews stated staff are limited to verbal interventions to stop an AWOL and bad behaviors and cannot physically restrain clients. Confidential interviews stated the facility provides a safe environment to clients in care however other witnesses allege otherwise. Confidential interviews contradicted the information provided and denied the allegations occurred however; other information provided alleged the incidents occurred. Based on confidential interviews, the allegations that due to a lack of staff supervision minor ingested pills resulting in death, client has access to weapons, client caused injury to another client in care, staff are not providing adequate supervision to clients, staff did not provide a safe environment to clients in care and staff did not report incidents may have occurred, however are not supported or proven by evidence. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this signed report was provided to Program Administrator, Yoshita Conrad.

Investigation Findings:
13On 12/21/2021, at 9:40 a.m. Licensing Program Analyst (LPA) Marisol Lopez arrived at the facility unannounced and met with Program Administrator Yoshita Conrad, of Circle of Friends to discuss the investigative findings for the allegation noted above. On June 08, 2021, Community Care Licensing's (CCL) Investigations Branch Bureau, Investigator Ernestina Bellucco, conducted the initial complaint investigation at the facility. The investigation for neglect/lack of care and supervision included interviews with one administrator, two staff, one sergeant, review of records and incidents. On June 21, 2021 at 3:30 p.m., Licensing Program Analyst (LPA) Marisol Lopez met with Program Administrator Yoshita Conrad to conduct an unannounced complaint investigation for the above stated allegations. LPA conducted a safety inspection and no deficiencies were observed at that time. During the investigation, LPA Lopez and Danielle Garcia conducted confidential interviews with Client #1-5 (C1-C5), Staff #1-2 (S1-S2), one social worker (SW) and Program Administrator (P1). LPA Lopez conducted additional confidential interviews with Client #6-8 (C6-C8), one program manager (P2), Staff #3-4 (S3-S4) and reviewed incident reports. (see continuation form LIC9099-C dated 12/21/2021) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Marisol Lopez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, METROPOLITAN DR. # FACILITY NAME: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 12/21/2021

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


raw_content:
Narrative:
Based on interviews and record reviews the allegations that staff engaged in substance and alcohol with C1, C2 and C3 and staff was communicating with the minors on social media., may have occurred, however is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Yoshita Conrad.

Investigation Findings:
13Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced inspection to the facility to deliver the findings of the above allegations. LPA met with Yoshita Conrad. On May 27, 2021 at 12:00pm LPA Marisol Lopez conducted a safety inspection at the facility and no deficiencies were observed at that time. LPA Lopez reviewed all of the client files. Five of Six of children (C1, C2, C3, C4, C5), county social workers, facility staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that staff ( name unknown) engaged in substance and alcohol with minors and that the staff was communicating with the minors on social media. Confidential staff interviews reported that on several occasions C1, C2 and C3 went absent without leave (awol) from the facility. Once the minors returned from being awol the minors would return intoxicated. Confidential interviews revealed that C1, C2 and C3 were consuming the alcohol and substance while out on awol and not at the facility. Confidential interviews reported that staff followed all awol protocols and notified all appropriate parties. LPA did not receive any further information regarding what staff member was allegedly engaging in alcohol, substance and communicating with the minors on social media. The interviews that were provided to the LPA were not consistent regarding the allegations. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 01/14/2022

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


raw_content:
Narrative:
Confidential interviews stated clients (C1-C4) were messing around, C1 was restrained and hand sanitizer was set on fire on C1's chest however, other versions of how the incident occurred were provided. Confidential interviews stated staff were unable to enter the room due to (C1-C4) barricading the door for a few minutes. Confidential interviews indicated that while S1 was attempting to open the door, S2 ran outside to the window attempting to gain sight of the clients, at which time C1 opened the bedroom door and indicated that C1 obtained a "rug burn" injury. Confidential interviews stated C4 was not supposed to be at the facility, staff asked C4 to leave and staff contacted law enforcement however law enforcement did not remove C4 from the facility. Confidential interviews stated staff are limited in how they can intervene and followed the facility emergency intervention plan by calling law enforcement. Records obtained indicted law enforcement was contacted and arrived at the facility. Although, C1 sustained a 2nd degree burn while in care, there were inconsistent statements from the suspects, witnesses, and victim as to what occurred and how staff responded to the incident. Based on confidential interviews, the allegations that Client #1 (C1) was injured while in care due to neglect or lack of supervision may have occurred, however are not supported or proven by evidence. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this signed report was provided to Program Representative, Jeannette Villarreal.

Investigation Findings:
13On 1/14/2022, at 11:30 a.m. Licensing Program Analyst (LPA) Marisol Lopez arrived at the facility unannounced and met with Program Representative Jeannette Villarreal, of Circle of Friends to discuss the investigative findings for the allegation noted above. On 09/09/2021, Community Care Licensing's (CCL) Investigations Branch Bureau (IB), Investigator Nikki Vo was assigned the investigation. On 09/13/2021 at 11: A.M., LPA conducted an initial complaint investigation and met with Facility Manager Freddy Macias. LPA conducted a safety inspection and no deficiencies were observed at that time. The investigation, consisted of confidential interviews with Client #1-4 (C1-C4), Staff #1-3 (S1-S3), three social workers (SW1- SW3), Program Administrator (P1) and review of documents: Incident reports and law enforcement documents. On 09/08/2021, the Department received an allegation that Client #1 (C1) was injured while in care due to neglect or lack of supervision. The report disclosed that C1's roommate and some of the other minors in the home attacked C1 in a room and put hand sanitizer on C1's chest and set C1 on fire. (see continuation form LIC9099-C dated 01/14/22) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Marisol Lopez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, METROPOLITAN DR. # FACILITY NAME: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 01/14/2022

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

met_with: Jeannette Villarreal


raw_content:
Narrative:
Other confidential interviews revealed that S1 specifically asked about adopting C1. Confidential interviews did not indicate that any boundaries were crossed between S1 and C1; however S1 was unable to be interviewed. S1 is no longer employed by the facility and S1's contact number is no longer in service. Based on confidential interviews, the allegation that Staff #1 (S1) had an inappropriate relationship with Client #1(C1) may have occurred, however are not supported or proven by evidence. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this signed report was provided to Program Representative Jeannette Villarreal.

Investigation Findings:
13On 1/14/2022, at 12:35 p.m. Licensing Program Analyst (LPA) Marisol Lopez arrived at the facility unannounced and met with Program Representative Jeannette Villarreal, of Circle of Friends to discuss the investigative findings for the allegation noted above. On September 13, 2021 at 12: P.M., LPA conducted an initial complaint investigation and met with Facility Manager Freddy Macias. LPA conducted a safety inspection and no deficiencies were observed at that time. During the investigation, LPA conducted confidential interviews with four clients (C1, C2, C3, C4), two social workers, three staff (S1, S2, P1, P2), one agency worker, and reviewed incident reports. On 09/09/2021, the Department received an allegation that Staff #1 (S1) had an inappropriate relationship with Client #1(C1). It was reported C1 had S1's personal phone number and S1 had asked about adopting C1. Confidential interviews revealed conflicting statements: C1 did not have possession of S1's phone number. Also, C1 had S1's phone number and requested to call S1 when C1 was placed in juvenile hall. Confidential interviews stated S1 had asked about adopting foster children. (see continuation form LIC9099-C dated 01/14/22) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Marisol Lopez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, METROPOLITAN DR. # FACILITY NAME: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 01/14/2022

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


raw_content:
Narrative:
It was also reported that C1 and Client #2 (C2) rubbed a dirty plunger on each other's' bed however conflicting interviews disclosed C1 and C2 threw feces in the bathroom, staff intervened and staff cleaned the area. Confidential interviews did not have any knowledge of two former clients physically assaulting C1 and/or stealing C1's personal belongings. Confidential interviews stated C1 has not reported any missing items however, it is unknown when the allegation may have occurred. Confidential interviews had conflicting statements on whether clients' needs were being met due to client's behaviors/allegations while in placement. Confidential interviews stated the facility follows the emergency intervention plan, intervenes between clients during any altercation/behavior and law enforcement is contacted as support when needed. Confidential interviews contradicted the information provided and denied the allegations occurred however; other information provided alleged the incidents occurred. Based on confidential interviews, the allegations that due to lack of supervision clients engaged in a physical altercation, staff failed to safeguard client's personal belongings, and staff failed to meet clients' needs may have occurred, however are not supported or proven by evidence. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this signed report was provided to Program Administrator, Yoshita Conrad.

Investigation Findings:
13On 2/07/2022, at 10:20 a.m. Licensing Program Analyst (LPA) Marisol Lopez arrived at the facility unannounced and met with Program Administrator Yoshita Conrad, of Circle of Friends to discuss the investigative findings for the allegation noted above. On December 21, 2021 at 11: A.M., LPA conducted an initial complaint investigation and met with Facility Administrator Yoshita Conrad. LPA conducted a safety inspection and no deficiencies were observed at that time. During the investigation, LPA conducted confidential interviews with two staff (S1,S2), one program administrator (P1), three of four social workers (SW1-SW4), three of four clients (C1-C4) and reviewed incident report. On 12/16/2021, the Department received an allegation that due to lack of supervision clients engaged in a physical altercation, staff failed to safeguard client's personal belongings, and staff failed to meet clients' needs. The report disclosed that an unknown staff, on an unknown date, allowed two former clients to physically assault Client #1(C1) and stole C1' personal belongings. (see continuation form LIC9099C dated 02/07/2022) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Marisol Lopez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, METROPOLITAN DR. # FACILITY NAME: CIRCLE OF FRIENDSFACILITY NUMBER: VISIT DATE: 02/07/2022

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


raw_content:
Investigation Findings:
13On November 29, 2022 at 1: PM, Licensing Program Analyst (LPA) Lucero Jauregui arrived unannounced to deliver an amendment to the report dated 10/20/2022, due to the document being delegated confidential and should be available for public view; no other changes were made to the document. LPA met with Jermaine Williams and provided a copy of this document. On October 20, 2022 at 09:35, Licensing Program Analyst (LPA) Lucero Jauregui arrived unannounced to the facility and met with Administrator Yoshita Conrad of Circle of Friends to discuss the investigative findings for the allegation noted above. LPA conducted an inspection with Licensing Program Analyst Eduardo Barragan with the facility on September 23, 2022 at 11: AM, no deficiencies were noted. During the investigation LPA's interviewed one staff (S3) and one of four clients (C1), C2 and C4 declined to interview, C3 was not involved in the incident. LPA reviewed C1's Needs and Services Plan and Special Incident Report. On September 19, 2022, the Department received an allegation of minor ingesting unknown medications while in care. It was reported C1 was found unresponsive and taken to Rady Children's Hospital. It was also reported the urine screen of C1 was presumptive positive for THC and benozodiazepine. Confidential interviews revealed that C1 consumed Xanax with C3 and C4. Confidential interviews revealed that C1, C3, C AWOLED two times that night. Confidential interviews revealed clients often break into the garage from the outside of the home including the night of this allegation. Confidential interviews revealed there are no clients in the home prescribed Xanax and there is no medication stored in the garage. Confidential interviews indicated that there were two staff present at the facility within ratio and conducted room checks. Confidential interviews entailed conflicting statements to whether the staff witnessed C1, C2, C4 ingest any substances. It is unknown where the clients obtained Xanax. Based on confidential interviews, the allegation of C1 ingesting unknown medications while in care due to lack of supervision, may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. Exit interview was conducted and copy of this report, along with appeal rights were explained and provided to Administrator Yoshita Conrad. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Yoshita Conrad, Administrator


facility_name: CIRCLE OF FRIENDS II

summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA), Tamara Melikian met with the Short Term Residential Therapeutic Program (STRTP) administrator and Facility Manager to discuss the investigative findings for the above stated allegations. LPAs Tamara Melikian and Marisol Lopez interviewed five of seven staff members (S1, S2, S3, S4, S5) and three of four former clients (C1, C2, C3) as well as reviewed client and facility records and obtained records from law enforcement. On October 17, 2022, Community Care Licensing received information alleging that the staff(unknown which staff) was not adequately supervising the youth's behavior and that the minor had access to a sharp object. Confidential interviews state that the staff is following the emergency intervention plan, however there are conflicting reports stating the staff is not adequately supervising the youth's behavior. In addition, confidential interviews state that the minor(C1) made a threat of having a sharp object, however, one could not be located. Some confidential interviews disclosed not really recalling any incident regarding C1 making threats with a sharp object. During LPAs Melikian and Lopez inspection to the facility, there were no observations of sharp objects accessible to the clients in care. Confidential interviews did not corroborate the allegation with a preponderance of evidence. Based on interviews and confidential information obtained during the course of this investigation, the allegations that the staff did not adequately supervise youth's behavior and that the minor had access to a sharp object may have occurred, however is not supported or proven by evidence. Therefore, the above allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Melanie Krage LICENSING EVALUATOR NAME: Tamara Melikian 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

met_with: Tammy Hudson


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA), Tamara Melikian met with the Short Term Residential Therapeutic Program (STRTP) administrator and Facility Manager to discuss the investigative findings for the above stated allegation. LPAs Tamara Melikian and Marisol Lopez interviewed five of seven staff members(S1-S7) and three of four former clients(C1, C2, C3) as well as reviewed client and facility records and obtained records from law enforcement. One client refused to be interviewed. On October 31, 2022, Community Care Licensing received information alleging that the staff(unknown which staff) was not providing adequate supervision to the minors while in care. Confidential interviews state that the staff is following the emergency intervention plan, however there are conflicting reports stating the staff is not providing adequate supervision. Confidential interviews did not corroborate the allegation with a preponderance of evidence. Based on interviews and confidential information obtained during the course of this investigation, the allegation that the staff are not providing adequate supervision to the minors while in care may have occurred, however is not supported or proven by evidence. Therefore, the above allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Melanie Krage LICENSING EVALUATOR NAME: Tamara Melikian 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


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
On May 18, 2023, the Department received an allegation that S1 provides marijuana to C1 in care. It was reported that S1 provides C1 marijuana. Confidential interviews stated S1 denied providing C1 any type of drug including marijuana. Confidential interviews revealed that clients feel safe at the facility with no concerns of being provided marijuana by staff members. There were no witnesses to the event. Based on confidential interviews, the allegation that S1 provides marijuana to C1 in care may have occurred, however is not supported, or proven by evidence. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this signed report was provided to Yoshita Conrad, Administrator.

Investigation Findings:
13On July 5 2023, at 1: PM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Yoshita Conrad, Administrator of Circle of Friends to discuss the investigative findings for the allegation noted above. On May 19, 2023, Community Care Licensing's (CCL) Investigations Branch Bureau (IB), Investigator Annette Renquist was assigned the investigation. On May 19, 2023 at 12: PM, LPA conducted an initial complaint investigation and met with Jeanette Villareal, Facility Representative. LPA conducted a safety inspection and no deficiencies were observed at that time. The investigation, consisted of confidential interviews with three Clients (C1-C3), four Staff (S1-4), Program Administrator (P1), County Social Worker (CSW1), two School Personnel (W1-2), and review of documents: incident reports, search procedure policy, and C1's needs and services plan. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SO. Cal Sc/res, Metropolitan Dr. # FACILITY NAME: CIRCLE OF FRIENDS IIFACILITY NUMBER: VISIT DATE: 07/05/2023

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0


raw_content:
Narrative:
Confidential interviews indicated overnight staff was not aware that C1 was not on any medication, but it is unknown if S1 would have been briefed on C1's medication if C1 was taking prescribed medications. Based on confidential interviews, the allegation that facility staff was unaware of C1's prescribed medications and facility staff refused to provide supervision for hospitalized youth, may have occurred, however is not supported, or proven by evidence. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this signed report along with appeal rights was provided to Yoshita Conrad, Administrator.

Investigation Findings:
13On January 5, 2024, at 9: AM, Licensing Program Analyst (LPA) Lucero Jauregui conducted an unannounced complaint inspection and met with Yoshita Conrad, Administrator. The purpose of the inspection is to deliver the findings for the above allegations. LPA conducted an inspection of the facility on July 5, 2023, and no deficiencies were noted. During the investigation LPA conducted three staff interviews (P1, S1,S2). On June 29, 2023, Community Care Licensing (CCL) received the allegations that S1 was unaware of clients prescribed medications and S1 refused to provide supervision for hospitalized youth. Confidential interviews indicated it was C1's first day at the facility, client was taken to school and AWOLed. Confidential interviews indicated C1 was taken to the hospital by law enforcement. Confidential interviews revealed conflicting statements as to whether staff was asked to provide supervision at the hospital. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SO. Cal Sc/res, Metropolitan Dr. # FACILITY NAME: CIRCLE OF FRIENDS IIFACILITY NUMBER: VISIT DATE: 01/05/2024

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0


raw_content:
Narrative:
Record review indicated C1 was placed at Circle of Friends II, where S1 worked at the facility, from January 2021 through June of 2021 and never during a Christmas season. Due to lack of interviews or other evidence to corroborate the allegation, the allegation is unsubstantiated. The allegation that staff sexually abused a minor while in care may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report and appeal rights was sent via US Postal Service Certified mail to the facility's last known mailing address.

Investigation Findings:
13On 09/10/2025, Licensing Program Analyst (LPA) Lucero Jauregui sent this LIC Complaint Investigation Report and appeal rights via US Postal Service certified mail to the facility's last known mailing address, as the facility has ceased operating. On July 25, 2025, Special Investigator (SI) Thomas Smith served initial complaint notice via US Postal Service certified mail to the last known facility business office. The investigation was conducted by Special Investigator (SI) Thomas Smith. During the investigation, SI interviewed one County Social Worker (CSW1) and one staff (S2). SI Smith attempted to interview one client (C1) and one staff (S1), however, after numerous attempts SI was unsuccessful. On July 16, 2025, Community Care Licensing (CCL) received an allegation that staff sexually abused a minor while in care. It was reported that C1 was sexually abused by a facility staff. It was reported that C1 was 15 years old and S1 invited C1 over to their home during Christmas break to have sexual relations. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: CIRCLE OF FRIENDS IIFACILITY NUMBER: VISIT DATE: 09/10/2025

visit_type: Complaint Investigation


summary: Facility Evaluation

raw_content:
Narrative:
On 06/21/19 at 1: P.M, Licensing Program Analyst (LPA) Marisol Lopez arrived at the above facility for the purpose of conducting a required/annual Inspection. LPA met with Program Administrator Yoshita Conrad and inspected the facility inside and out. The facility consists of a one story, four-bedroom, two bathroom with a staff office at the entrance, laundry room, kitchen, with pantry, living room, family room and dining area. There is a current census of three clients. Bedroom #1 is occupied by one client; it contains one twin bed, all required linen, mattress, closet space and dresser with enough space for clients belongings. Bedroom #2 is not occupied; it contains one twin bed, all required linen, mattress, closet space and dresser with enough space for clients belongings. Bedroom #3 is occupied by one client; it contains two twin beds, all required linen, mattress, closet space and dresser with enough space for clients belongings. Bedroom #4 is occupied by one client; it contains two twin beds, all required linen, mattress, closet space and dresser with enough space for clients belongings. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/books/games were observed for client's recreation time. LPA observed sufficient perishable food for six clients for two days and seven days of non-perishable foods and appears to be following the posted menu. LPA tested the water temperature which measured 116.0 degrees Fahrenheit(F) which is within the acceptable range of 105 degrees and 120 degrees. The hallway closet contains extra linen, wash cloths, towels and bed sheets. The closet contains mop, brooms and a vacuum. The staff office contains two desks, office supplies, file cabinet with office supplies, a large locked file cabinet that contains medications triple locked, sharps and first aid kit double locked. Personnel files were reviewed to ensure they contained all required documentation. Children and staff records are organized. Staff's CPR and First Aid card were current. Child's records contain original needs and services plan signed by the child and their authorized rep. Child's records contain authorization for emergency medical care signed by each child's authorized rep. Licensee has a current needs and services plan for each resident on file. Facility personnel meet staff training requirements Program Administrator is present at the facility a minimum of 20 hours a week, as verified by staff schedule. Appropriate staff/client ratios were verified during this inspection. Based on observations made during the inspection, no deficiencies observed during today's visit. An exit interview was conducted and this report was reviewed with Administrator Yoshita Conrad and a copy of this report was provided. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The laundry room contains a washer and dryer. The living room contains a large screen TV, two couches, kitchen bar seating with two bar chairs and a dining area with six chairs. The family room contains a couch, television, game system, board games, as well as books for the client's entertainment. LPA observed the bathrooms were clean and in good repair. In the garage LPA observed a second refrigerator, an extra freezer filled with food, locked medications refrigerator, locked cabinets with tools, chemicals and poisons in a locked cabinet, office equipment, extra storage and locked storage cabinets for clients use. All hazardous items were made inaccessible to clients. The facility's smoke detectors located in each of the bedrooms and the living room and office were checked and were operable. The carbon monoxide detector located in the hallway area was tested and is in operable condition. The single fire extinguisher has a current inspection tag. The following required posted items were observed and accessible to children: Ombudsman Poster, Foster Youth Bill of Rights, Grievance Procedures, Personal Rights, and current menu. LPA observed that the personal rights was updated to meet the current Interim Licensing Standards (ILS). Per facility staff, no firearms or weapons are allowed in the facility. Facility appears to be meeting the terms and conditions of their license. Licensee has obtained National Accreditation through CARF and the Accreditation is valid through November 2021. LPA discussed the following with the Program Manager: Incident reporting, including incidents related to Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. Personnel Files are maintained off-site and transported to LPA within reasonable time. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. A review of client records was also completed on this date including the Medication Administration Record (See Confidential Name List- LIC 811 dated on June 21, 2021).


summary: Facility Evaluation

raw_content:
Narrative:
On October 21, 2021 at 10: AM, Licensing Program Analysts (LPA) Marisol Lopez conducted an unannounced inspection at the above facility. During the inspection, LPA met with Program Representative (P1) Robert Brevick. LPA conducted telephone call with Program Administrator Yoshita Conrad who designated P1 to facilitate inspection and sign document (LIC-809 dated 10/21/21). LPA conducted a safety inspection of the facility, and no safety hazards were observed. The purpose of the case management inspection is to conduct a record review. Community Care Licensing (CCL) has requested the following documents to be submitted to LPA within 48 hours. LIC LIC Control of Property An exit interview was conducted and this report was reviewed with Program Representative Robert Brevick and a copy of this report was provided.

met_with: Robert Brevick


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Manager Angela King and Licensing Program Analyst Sethany Yem conducted a case management inspection on 7/26/22 based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 10 out of Direct Care Staff and 3 out of 3 youth files were reviewed. 4 out of Direct Care Staff and 3 out of 3 youth were interviewed. (See the Confidential Names List, LIC 811, dated July 26th, 2022). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth case plans, quarterly assessments, and crisis intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPM King and LPA Yem observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Administrator Yoshita Conrad.

met_with: Administrator Yoshita Conrad


facility_name: CLAIRE'S HOUSE

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Christopher Rollins made an unannounced annual inspection to this facility. LPA met with Christopher Martinez Chief Program Officer (CPO) and Mary Kuhn Deputy Chief of Communication (DCOC) The facility is licensed for 12 residents (all can be ambulatory) ages 12-17 and currently 0 clients reside in facility. The facility consists of 8 bedrooms (8 double occupancy rooms for clients) and 7 bathrooms (5 for clients and 2 for staff). The facility also has 5 additional rooms which are Director office, Meditation room, Classroom, Staff break room and staff work room. No more than two clients to a room. At 03: PM, LPA Rollins, CPO and DCOC toured the facility inside and out. The kitchen is clean. The hot water in the bathroom and kitchen measured at 114 degrees F which is currently between 105 - 120 degrees. The facility has plenty of nonperishable and perishable food supply. Medication, cleaning supplies and knives are 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. LPA observed first aid kit to be fully stocked. The home is maintained at a comfortable temperature. Personal rights, floor plan, food menu and Emergency disaster forms were posted and in clear view. LPA Rollins did not review any staff or client files because currently the facility does not have any working staff or clients in the facility. During inspection, A review of Licensing Information System on September 14, 2021 indicates that all facility staff associated to the program has DOJ, FBI and child abuse index check clearances. Per Title Regulations, no deficiencies were cited during this inspection. Exit interview conducted and a copy of the report was left at the facility.

met_with: Christopher Martinez-Chief Program Officer and Mary Kuhn- Deputy Chief of Communication


facility_name: COMMUNITY ACCESS NETWORK STEPS 2

raw_content:
Narrative:
Regarding the allegation that facility staff did not follow the Emergency Intervention Plan to prevent minors from AWOLing, information gathered from interviews stated that facility staff are trained and go over the emergency intervention procedures in accordance with their plan of operation. Confidential interviews disclosed that facility staff attempts to redirect clients and engage in other activities when they express that they want to AWOL. In addition, confidential interviews stated that staff will follow clients in care until they lose sight of clients. Other interviews revealed that staff will go over the emergency plan with resident clients in care. Other information received stated that staff were not always following their emergency intervention plans resulting in client's chronic AWOL. Regarding the allegation that the facility is allowing minor unapproved visits in care, confidential interviews stated that clients at times would not follow program rules and would invite unauthorized visitors to the facility. Information obtained from confidential interviews stated that the facility staff would contact law enforcement to report when unauthorized visitors were at the facility while other confidential interviews stated staff would allow unauthorized visitors to come to the facility. Regarding the allegation that group home minors are intoxicated while in care, confidential interviews confirmed that minors are intoxicated while in care however it is upon returning from AWOL's. Additional information gathered stated that when clients are absent from care they may sometimes return to the facility under the influence. Staff will offer clients medical attention and will contact law enforcement if staff cannot talk clients down from intoxication. Additional information gathered from interviews denied the allegation that clients get intoxicated in the facility or under the supervision of staff. Based on interviews and confidential information obtained during the course of this investigation, LPA received inconsistent information regarding the allegations. The allegations that facility staff did not follow the Emergency Intervention Plan to prevent minors from AWOLing, facility is allowing minor unapproved visits in care, and group home minors are intoxicated while in care, may have occurred, however is not supported, or proven by evidence. Therefore, the above allegations are unsubstantiated at this time. Exit interview conducted and a copy of the report along with appeal rights were provided to Administrator Assistant, Guadalupe Arellano.

Investigation Findings:
13On March 21, 2023 at 9:40 am Licensing Program Manager (LPM), Natasha Dunlap, and Licensing Program Analyst (LPA), Emina Preciado, met with Community Access Network Steps 2, Short Term Residential Therapeutic Program (STRTP), Administrator Assistant, Guadalupe Arellano, to deliver the findings for the above stated allegations. LPA Lisi Leon conducted an inspection of the facility on March 30, 2022 at approximately 10:15 am and no immediate deficiencies were observed. The investigation included interviews with three staff (S1, S2, and S3), two foster youth (C1 and C2). Four confidential witnesses did not respond to LPA's request for an interview, after multiple attempts, and therefore were not interviewed. In addition, county records and facility records were reviewed. On March 28, 2022, Community Care Licensing (CCL) received an allegation alleging that facility staff did not follow the Emergency Intervention plan to prevent minors from AWOLing, facility is allowing minor unapproved visits in care, and group home minors are intoxicated while in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Emina Preciado LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: COMMUNITY ACCESS NETWORK STEPS 2FACILITY NUMBER: VISIT DATE: 03/21/2023

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

met_with: Guadalupe Arellano, Administrator Assistant


summary: Facility Evaluation

raw_content:
Narrative:
On August 31, 2020, at 11: AM, Licensing Program Analyst (LPA) Belinda Torres conducted a Short Term Residential Therapeutic Program (STRTP) pre-licensing inspection. The LPA met with Rafik Philobos, Executive Director. The licensee is temporarily relocating from the Community Access Network (CAN) facility number 336426251, Steps STRTP located at Tava Lane Riverside, CA 92505 to this facility. The CAN Steps STRTP has a septic system failure. The clients can no longer be present due to health and safety issues. The licensee expects to complete the relocation move within the next two weeks. Let it be noted the street name for this facility is spelled incorrectly and was corrected yesterday to Briarwood Dr. The correction takes up to 48 hours to update in the CCL database. The facility is a two story residential building with four bedrooms and three bathrooms. The facility is currently unfurnished. On the first floor, there is one bedroom, one staff office with a staff restroom, kitchen, dining area, great room, and laundry room. There is a two car attached garage. In addition, there is a separate casita with one bedroom and one bath. The casita is used for the corporation's foster family agency storage. The clients will not have access to the casita. A physical plant inspection was completed with Rafik. The LPA observed the following: Facility grounds are clean and free of debris, observable hazards, and insects. The LPA observed an approximately 4" x 5" hole in the wall and the window blinds were missing a slat in bedroom #6 (second floor). The hole was patched during this inspection. There was no screen on the staff office window (first floor) There is adequate indoor and outdoor activity space. All facility smoke detectors and the one carbon monoxide detector downstairs were tested and observed to be in working order. A fire clearance is still needed. Per Rafik, the facility has an operating telephone line but there was no phone equipment to test the line. The LPA called the number, (951) 277-0016, and it appeared to be operating. The hot water was tested and measured to be 115 degrees Fahrenheit downstairs and Fahrenheit upstairs. The downstairs water temperature is in the required range of 105-120 degrees Fahrenheit, however the upstairs was not. The water heater temperature was adjusted during the inspection from the "very hot" setting to the "hot" setting. Per Rafik, no firearms or dangerous weapons will be kept or allowed in the facility. Smoking is prohibited. *** *** The LPA informed Rafik of the Interim Licensing Standards, Articles 1-10, 87088(e)(2) and (f) Fixtures, Furniture, Equipment, and Supplies which states the following facilities shall maintain a signal system which meets the requirements specified in (e) and (f) below. Such system shall be used by children to summon staff during an emergency: (2) All facilities having separate floors and not providing full-time staff on each floor whenever children are present. (f) The signal system shall have the ability to meet the following requirements: (1) Operation from each children's living unit. (2) Transmission of a visual and/or auditory signal to a central location, or production of an auditory signal at the specific children's living unit which is loud enough to summon staff. (3) Identification of the specific children's living unit from which the signal originates. Rafik stated the facility will have a full-time staff on each floor whenever children are present. Once the facility has relocated, the licensee will ensure that photos will be sent to LPA Torres including but not limited to: Furniture, fixtures and equipment. Locked storage for personnel files, client files, medications, sharps and client funds. The following required forms posted in the facility: Weekly Menu, Personal Rights form, and Foster Care Ombudsman poster. Each of the four client bedrooms having proper lighting, adequate drawer space, beds with appropriate clean linens, pillows, blankets, comforters, mattress pads, and mattresses in good repair. A fully equipped first aid kit and a current first aid manual approved by the American Red Cross. Hot water reading for the second floor bathroom. The following documents will be sent to LPA Torres: Updated LIC Facility Sketch reflecting the usage for each room, dimensions and exits. Updated LIC Application For A Community Care Facility with the current facility telephone number and the correct facility number and licensing agency for question #14. Control of property. LIC 610C Emergency Disaster Plan For Residential Facilities. After final review of the application, the program will be submitted for licensure. An exit interview was conducted and a copy of this report was provided.

visit_type: Prelicensing

met_with: Rafik Philobos


summary: Facility Evaluation

raw_content:
Narrative:
On March 10, 2022, Licensing Program Analyst (LPA) Michael Almaraz arrived at Community Access Network Short Term Residential Therapeutic Program (STRTP) and met with facility manager Breana Areyan. The purpose of the inspection was to interview client #1 (C1) see confidential names list (LIC 811) dated March 10, 2022, in regard to a previous placement. A copy of the LIC 811 and LIC 809 was provided and explained to Breana Areyan.

met_with: Breana Areyan


summary: Facility Evaluation

raw_content:
Narrative:
On July 27, 2022, Licensing Program Analyst (LPA), Lisi Leon, met with Community Access Network Steps 2, CEO, Rafik Philobos, to provide a copy of the technical violation issued on 07/20/2022. LPA met with CEO at Community Access Network FFA/STRTP Headquarters located at: S Main St, Suite 201, Corona, CA 92882.

met_with: CEO, Rafik Philobos


summary: Facility Evaluation

raw_content:
Narrative:
On 10/17/2023, at 10:00 am, Licensing Program Analyst (LPA), Sarah Lo, arrived at Community Access Network Steps Short Term Residential Therapeutic Program (STRTP) located at Briarwood Dr, Corona, Ca 92883. LPA was met at the facility by Rafik Philobos, Executive Director and Margeaux Wilkins, Executive Assistant at 10:51 am whom allowed access into the facility for an inspection. The purpose of the visit is to conduct an unannounced required annual inspection of the facility. Per Margeaux Wilkins, there are no clients placed at the facility and the facility has been vacant since April 2021 and there are no staff working for this location. A physical plant inspection was completed and included the facility's kitchen area, refrigerator/freezer, food storage areas, three client rooms, three bathroom/showers, and community gathering area and dining area. LPA began a physical plant inspection at 11:05 am and the tour of the physical plant inspection was completed with Rafik Philobos, Executive Director and Margeaux Wilkins and included the following checks: Facility grounds are clean and free of debris and hazards free. There is adequate indoor and outdoor activity space, including a basketball court. Puzzles, books, board games were observed for client's recreation time. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of non-perishable foods and there were no perishable food because there is no client residing at the facility at the moment. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, the Emergency Disaster Plan was also posted. Medications are locked and centrally stored in the facility staff's office inside a locked file cabinet. Chemicals/poisons are locked outside in the casita. Sharp objects and knifes are stored in the staff office inside a locked file cabinet. The facility staff's office always remains locked. First Aid Kits are also stored in the staff office and are complete. Licensee has provisions for contraceptives to be held in individually locked containers by clients. *continued on LIC 9099-c* Licensee has obtained National Accreditation through COA. The Accreditation is valid through February 08, 2026. Licensee has obtained Mental Health Approval valid through December 11, 2023. There is currently a Licensing fee balance of zero. There are three bedrooms with two twin beds in each room. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. Each bedroom has a dresser for each client that provides more than three drawers of storage and a closet for additional storage. Bedrooms are arranged so that no more than two clients share a room and there is one client per bed. There are three full bathrooms in the home. The hot water in the client's bathroom was deemed to be safe and measured to be 110.6- and 115.6-degrees Fahrenheit in bathroom #1 and 115.4- and 112.4-degrees Fahrenheit in bathroom #2 and 113.6- and 115.2-degrees. Per Rafik Philobos, Executive Director, no firearms, or weapons are allowed in the facility. There are no staff on-site due to no clients at the facility. Executive Director verified the Board of Directors are meeting quarterly and provided board meeting minutes. During the inspection, LPA reviewed one staff file and the file met the minimum requirement per Title Regulations. Personnel files are maintained off-site in a locked cabinet in the corporate office located in Corona and Esmeralda Rivera, HR Representative was able to bring over the requested file for review. All personnel records reviewed have the verification of Department of Justice, Federal Bureau of Investigations, and Child Abuse Index Check clearances. All staff have proof in file of acknowledging confidentiality and mandated child abuse reporting requirements. All personnel records reviewed met the required education and experience requirement. All personnel records reviewed had a completed physical exam on file. CPR/First Aid Certificates were observed and were valid. Per Rafik Philobos, Executive Director, due to no clients are residing at the facility, there is no other staff assigned to this facility and will remove the staffs that are currently associated with this facility off Guardian. During the inspection, LPA did not review any client files due to no clients at the facility. No deficiencies were found during this inspection. An exit interview was conducted and a copy of this report was provided to Margeaux Wilkins, Executive Assistant.

met_with: Rafik Philobos, Executive Director Margeaux Wilkins, Executive Assistant


facility_name: COMMUNITY ACCESS NETWORK YOUTH DEV CTR S.T.E.P.S.

raw_content:
Narrative:
On April 4, 2023, Community Care Licensing (CCL) received a complaint alleging that the Staff allow minors in care to engage in inappropriate activities, and Staff did not intervene on minor's substance consumption. Specifically, It was reported that Staff would give the children boxing gloves, while staff would watch and laugh ,while they fought. A Client also reportedly used some sort of substance, and staff knew about it and did not report it. Regarding the allegation that Staff allow minors in care to engage in inappropriate activities. Confidential interviews stated that an approved boxing activity did occur under staff supervised conditions. When clients began to misuse the boxing activity by engaging one another unsupervised, staff terminated the activity permanently for all clients. Other information stated the allegation occurred. Regarding the allegation that the Staff did not intervene in minor's substance consumption. Confidential interviews stated that there was substance consumption witnessed by Staff. However, Staff acted to intervene and positively support the client involved. Other information stated the allegation occurred. Based on confidential interviews the preponderance of evidence standard has not been met and the allegations that the Staff allow minors in care to engage in inappropriate activities, and Staff did not intervene on minor C3's substance consumption, may have happened or are valid, but there is not a preponderance of evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted. A copy of this report, along with Appeals Rights were explained and provided to the STRTP Administrator.

Investigation Findings:
UnsubstantiatedEstimated Days of Completion: 90-Days Estimated Days of Completion: 90-Days Estimated Days of Completion: 90-Days

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

met_with: Doris Casas, Associate Clinical Social Worker


raw_content:
Narrative:
On December 26, 2023, Community Care Licensing (CCL) received a complaint alleging that the facility sink is in disrepair. Specifically, it was reported that the facility sink is clogged and causing a fall risk due to water everywhere. Further reported information stated that the kitchen sink has been clogged and overflowing throughout the entire kitchen since 12/23/2023. Regarding the allegation that the facility sink is in disrepair. Confidential interviews stated that the facility kitchen sink was clogged and drained at a slow rate but did not overflow onto the floor. Staff acted to repair the sink and the sink was repaired on the next available business day on December 26, 2023, due to the Christmas Holiday. Other information stated the allegation occurred. Based on confidential interviews the preponderance of evidence standard has not been met and the allegation that the facility sink is in disrepair, may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated at this time. Exit interview was conducted. A copy of this report, along with Appeals Rights were explained and provided to the STRTP Residential Youth Counselor, Jennifer Salanic.

Investigation Findings:
UnsubstantiatedEstimated Days of Completion: 90-Days Estimated Days of Completion: 90-Days Estimated Days of Completion: 90-Days

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


summary: Complaint Investigation - Unsubstantiated - 2 allegations

raw_content:
Narrative:
On January 2, 2024, Community Care Licensing (CCL) received a complaint alleging that Staff are serving food at the facility that a youth in care is allergic to. Specifically, it was reported that this is highly unsafe the for the health of this dependent as it is completely disregarding this dependents health condition. It is also highly inconsiderate to make a dish or meal that a resident is unable to consume. Regarding the allegation that Staff are serving food at the facility that a youth in care is allergic to. Confidential interviews stated that the Staff do prepare meals containing shellfish for the other clients at the facility. However, full alternative meals are available for the client with the allergy and safeguards, such as cleaning procedures are taken by staff to ensure the client's personal rights are not violated. Further investigation revealed that the allergy is a safety concern only if ingestion of shellfish occurs. Other information stated the allegation occurred. Based on confidential interviews the preponderance of evidence standard has not been met and the allegation that Staff are serving food at the facility that a youth in care is allergic to, may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated at this time. Exit interview was conducted. A copy of this report, along with Appeals Rights were explained and provided to the STRTP Residential Youth Counselor.

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

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

met_with: Residential Youth Counselor, Jennifer Salanic


raw_content:
Narrative:
(Continued from LIC9099) Confidential interviews indicated that staff provided mental health and therapist counseling to C1 and attempted to stop C1 from absconding from the facility. Confidential interview indicated staff provided transportation to and from the school of C1's choice to assist in their placement at the facility. A confidential interview also indicated staff provided adequate care to youth, even though the care could improve. Based on a lack of evidence to corroborate the allegation, the allegation that the staff does not ensure adequate care is being provided to minor is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report and appeal rights were discussed and provided to Mayra Rosas, Lead Facility Manager (LFM).

Investigation Findings:
13On January 9, 2025, at 1: PM, Licensing Program Analyst (LPA) Cynthia Velasquez met with Community Access Network Youth Dev. Ctr. S.T.E.P.S. Mayra Rosas, Lead Facility Manager (LFM) to deliver the finding for the above complaint allegation. On 09/03/24 at 1: PM LPA Cynthia Velasquez inspected the physical plant; deficiencies observed were mitigated during the visit and subsequently cited. The investigation included interviews with Children (C1 and C2), Staff (S1-S3), and County Social Worker (CSW). Pertinent records were obtained. On August 29, 2024, the Department received an allegation that the staff does not ensure adequate care is being provided to minor. It was reported that C1 was placed in the facility in April 2024, but C1 is no longer in the facility. It was reported that C1 was absent without leave (AWOL) from the facility in April 2024. It was reported that C1 has untreated mental illness and does not want therapy services or medication. It was also reported that whenever C1's caseworker tries to get services for C1, C1 will go AWOL. (Continued on LIC9099C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Cynthia Ann Velasquez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., Suite Riverside, CA Facility Name: Community Access Network Youth Dev Ctr S.T.E.P.S.FACILITY NUMBER: VISIT DATE: 01/09/2025

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

met_with: Mayra Rosas, Lead Facility Manager


raw_content:
Narrative:
This is an amended version of the original report created on 09/26/ Another confidential interview revealed that C2 provoked a verbal altercation between C1 and C4 regarding dishes left in the sink. Confidential interview disclosed that S2 allowed the altercation to occur. Confidential interview revealed that C1 called C2 a racial slur and C2 slapped C1 in the face. Confidential interview disclosed that C1 kicked C2 in the leg and they both fell near the stairs in the living room. Confidential interview revealed that Staff assisted when the two were both on the ground; as they told C2 to go to their room and asked C1 to accompany them outdoors. Confidential interview disclosed that after going outside with staff, C1 refused to return inside. Other confidential interview disclosed that S2 allowed C2 to initiate a discussion with C4 and C1 regarding tasks not being performed in the kitchen. Confidential interview revealed that the discussion became heated between C2 and C1, and the two went different ways. Confidential interview disclosed that afterward, C1 and C2 met in the hallway, and C2 was the first youth to become physically assaultive. Confidential interview revealed that staff were available after the incident occurred. A confidential interview indicated staff separated the youth once the altercation became physical. A conflicting confidential interview indicated that staff assisted once C1 and C2 were already involved in the altercation and on the ground. Another confidential interview indicated that staff came to assist when staff became aware the altercation occurred. Based on conflicting interviews, the allegation that staff did not prevent a minor from being physically assaulted while in care is unsubstantiated. The allegation may have occurred or is valid, however there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report and appeal rights were discussed and provided to STRTP Mayra Rosas, Lead Facility Manager.

Investigation Findings:
13This is an amended version of the original report created on 09/26/ On September 26, 2025, Licensing Program Analyst (LPA) Cynthia Velasquez met with Jacqueline Gonzalez, Lead Facility Manager, to deliver the finding for the above-stated allegation. On June 27, 2025, LPA inspected the facility's physical plant, and no immediate health and safety hazards were observed. The investigation included interviews with clients in care (C1, C2, C3) and Staff (S1, S2) with an attempt to interview S3, C4, and C5, which were either refused or non-responsive. Pertinent records were obtained. On June 24, 2025, Community Care Licensing (CCL) received a complaint alleging that staff did not prevent a minor from being physically assaulted while in care. Specifically, it was reported that C1 no longer felt safe at the facility due to being beaten by an unidentified male in the facility. Confidential interview reported that staff were present during a verbal confrontation between C1 and C2 and separated the two once the altercation became physical. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Cynthia Ann Velasquez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., Suite Riverside, CA Facility Name: Community Access Network Youth Dev Ctr S.T.E.P.S.FACILITY NUMBER: VISIT DATE: 09/26/2025


summary: Facility Evaluation

raw_content:
Narrative:
On June 10, 2022 at 1:30pm, Licensing Program Analysts (LPAs) Shanae Pharaoh and Rafael Enriquez made a collateral visit to the STRTP to interview FC1 regarding a previous placement.

met_with: Head of Service -Aaliyah Wilburn


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Annual/Required inspection was conducted by Licensing Program Analysts (LPAs) Jose Gonzalez and Michael Almaraz on December 2, 2022, at 8: AM. LPAs were greeted at the door by Head of Service (HS), Aaliyah Wilburn. At the time of arrival there was two residents, two facility staff, Administrator (AD), and HS on site. Aaliyah Wilburn contacted Division Head of Residential Care Programs to request four staff members records be brought to the facility. The facility converted from a Group Home to STRTP (Short Term ResidentialTherapeutic Program) on March 5, 2019. At 9: AM, LPAs began the facility tour inside and out with the staff Wilburn. Facility grounds were clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. The interior check of the facility noted the following. Bedroom #1 is occupied by two client and had two twin beds. Bedroom #2 is occupied by two clients and had two twin beds. Bedroom #3 is occupied by two clients and had two twin beds. Bedroom #4 has been converted to a staff office. There was adequate shelf and closet space for client's belongings. The residents have access to two restrooms. Restroom #1 is located outside the staff office. This restroom was in good repair and the temperature of the water was measured at 111 degrees which is in regulation of (105-120 degrees). Sports equipment/toys/books/games were observed for children's recreation time. The facility smoke detectors located in bedrooms 1,2, and 3, outside and inside the staff office, living room, kitchen and hallway were operable; fire extinguisher is properly charged and serviced. There is a three-car garage that is locked and used for storage of maintenance items (ie. wood, doors, screening, etc.). The facility has no bodies water. *****CONTINUED on LIC 809C****** All hazardous items were made inaccessible, ensuring clients do not have access. Cleansers/chemicals were stored in a locked closet inside the facility staff office. Sharp knives were inaccessible and stored in a locked box in the closet in the staff office. The First Aid Kit is also located in staff office closet. It contained all required supplies. Facility had a one-week supply of non-perishable foods and two days of perishable foods, including nutritious snacks and had items available as to follow the posted menu. All required forms are posted including the Complaint/Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster. Medications are stored in the locked staff office and are stored in a locked container located in the locked closet making them triple locked and unavailable to clients. Administrator, Christopher Fowler is present at the facility a minimum of 20 hours a week, as verified by staff schedules. Staff/client ratios were verified during this inspection, and they were in accordance with the regulations. Licensee had obtained their Mental Health (MH) Certification in December 12, 2021. Facility obtained National Accreditation through Counsel on Accreditation (COA). Three clients (C1, C2, and C3) and four staff records (S1, S2, S3, and S4) were reviewed on this date to ensure they contained all required documentation per Interim Licensing Standards. Three out of the six clients were in school at the time of the inspection. Facility appears to be meeting the terms and conditions of their license. Licensing fees have been paid and there is currently a balance of zero. The facility is being cited for violation of the Interim Licensing Standards, Chapter 7. Short Term Residential Therapeutic Program, Articles 1 through 10, Version Building and Grounds 87087(e). LPA provided a copy of these reports, along with appeal rights, to Administrator, Christopher Fowler.

met_with: Christopher Fowler


summary: Facility Evaluation

raw_content:
Narrative:
On February 23, 2024, Licensing Program Analyst (LPA), Jason Dalton met with Residential Youth Counselor, Jennifer Salanic for the purpose of obtaining a signature. A copy of this report was provided to Residential Youth Counselor, Jennifer Salanic.