summary: Facility Evaluation

raw_content:
Narrative:
On September 23, 2025, 9:20am, Licensing Program Analyst (LPA) Emelyn Sanchez P. arrived at Ascend Healthcare 3, for the purpose of conducting an Annual/Required inspection visit. LPA Sanchez P. met with Brenda Reyes, Regional Operations Manager and was granted access into the facility. LPA Sanchez P. toured the interior and exterior of the facility. The facility is a private pay treatment program licensed to provide care and supervision services to six (6) children, ages 12-17 years old, ambulatory only. There is a swimming pool on the premises which meets licensing requirements. The census at the time of the inspection was five (5). The facility is a one story, 4-bedroom, 2 and a half-bathroom house with a living room, dining room, kitchen, laundry area, staff/therapy office, equine therapy farm, a pool, detached garage, and a backyard. The facility is set up as follows: Living room: is furnished with a sectional sofa and an operable wood burning fireplace equipped with an iron screen. Dining room: is furnished with a wooden table, six (6) chairs, and an operable wood burning fireplace equipped with a screen. Kitchen: is equipped with a gas operated 4-burner stove that includes a 2 burner-grill with a flat top stove, a microwave, refrigerator/freezer, a dishwasher, and a pantry. Sharp knives are kept in a locked box in a locked kitchen cabinet. Report Cont. on LIC 809-C Pg. 1 of Bedrooms: 3 bedrooms are used for clients and all rooms are furnished with two twin size beds, have closet space, working lights, and windows. The 4th bedroom is used for storage. Bathrooms: The half bathroom is located near the Nurse/Medicine office; the second full bathroom is located along the hallway adjacent to bedroom #3; and the third full bathroom is located inside bedroom #3. All bathrooms were checked and found to be in good repair and working order. The hot water temperature was tested and found to be between 105-120 degrees (F). Laundry area: is adjacent to the kitchen, equipped with washer and dryer. Nurse/Medicine office: is equipped with a computer, chair, desk, locked cabinets used to store files, hygiene supplies, and client medications. Medications that require refrigeration are stored in a double locked refrigerator located in the nurse/medicine office. The office remains locked and made inaccessible to clients in care. Equine therapy farm: is enclosed by a gate. The following animals are present: 2 goats, 3 miniature horses, 3 donkeys, 1 horse, 1 pig and chickens. There are 2 locked storage bins next to the farm; one contains animal food and supplies; the other is used for equipment/storage. Pool: is located in the backyard and is equipped with the required 5-foot fence, that does not obscure the pool from view, and a self-closing latch. The pool also has a regulation pool cover. Staff/Therapy office: has two (2) rooms for therapy sessions, a small kitchenette for staff, and a bathroom with a toilet, sink, and shower. Garage: has been converted into a classroom that includes six (6) computers, computer desk, chairs, a long table with extra chairs, and two (2) locked cabinets that store school supplies. Backyard: is equipped with a cement wood burning barbecue pit, a propane grill, a fireplace equipped with a screen. Report Cont. on LIC 809-C Pg. 2 of LPA Sanchez P. tested the carbon monoxide and smoke detectors and found them to be in working order. The facility has 5 fire extinguishers all in working order. The first Aid Kit is located inside the Nurse/Medicine office and was found to be complete. The facility has a working telephone readily accessible. The food menu is posted in the kitchen area and facility has non-perishable foods for one-week, and perishable foods for two days, the facility has a private chef, and all meals are prepared off site at Ascend Healthcare #7. Clients are also provided nutritious snacks between meals. Overall LPA Sanchez P. observed the facility to be clean, safe, sanitary and in good repair. The front yard and outdoor recreation area were clean and free of debris. The front yard contains a pond equipped with a security net. Passageways were unobstructed. There are no firearms or dangerous weapons in the facility. There are no security bars on the windows. Temperatures in client rooms are maintained through central air and heating and common areas were found to be between 68 - 85 degrees (F). The facility operates within license conditions and limitations including capacity limitations. LPA Sanchez P. discussed and advised the Regional Operations Manager to ensure the following: Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. Children are supported and encouraged to participate in extracurricular activities. LPA Sanchez P. reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. All posting requirements for Group Home Licensure and Emergency Plan were met. LPA was provided with a copy of the Personnel Report (LIC 500) and Client Register (LIC 9020). LPA will return at a later date to review client and staff records. There are no deficiencies observed or cited at this time during this inspection. An exit interview was conducted with Brenda Reyes, Regional Operations Manager, and a copy of this report was left at the facility. Pg. 3 of 3


state: CA

facility_name: ASCEND HEALTHCARE 3

summary: Facility Evaluation

raw_content:
Narrative:
On October 2, 2025 at 9:00am, Licensing Program Analyst (LPA) Emelyn Sanchez P. made an unannounced visit to Ascend Healthcare 3 for the purpose of conducting a Case Management- Annual Continuation Inspection. LPA Sanchez P. met with Brenda Reyes, Regional Operations Manager. LPA Sanchez P. was granted access to the facility. The facility keeps staff and client files and documents in digital system called KIPU and Isolved. LPA reviewed the following records during the inspection: Client Records: The program currently has a total of five (5) clients. LPA Sanchez P. reviewed five client records and found each record to meet licensing requirements. Staff Records: The program currently has a total of twenty-three (23) staff. LPA reviewed a total of five (5) staff records and confirmed files contained staff qualifications, current CPR/First Aid cards, required training hours, health screening, and TB test results. LPA Sanchez P. obtained the LIC 500 to verify staff to client ratio. LPA reviewed the Facility Profile and Personnel Report and confirmed that personnel have required criminal record clearance: DOJ, FBI and Child Abuse; which meet licensing requirements. LPA Sanchez P. conducted interviews with three (3) clients and a total of three (3) staff. Per California Code Regulations, TITLE 22, DIVISION 6, CHAPTERS 5 no deficiencies were cited. An exit interview was conducted, and a copy of this report was left with Brenda Reyes, Regional Operations Manager

report_type: Facility Evaluation

visit_type: Case Management


facility_name: ASCEND HEALTHCARE 4

summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13On 08/25/2022 at 12pm, Licensing Program Analyst (LPA) Bernice Karnsrithong arrived at the facility for the purpose of delivering findings for the above complaint investigation. Health and safety risk assessment was conducted upon arriving at the facility. LPA Karnsrithong met with Brenda Reyes, Facility Manager who granted access to the facility. During the investigation of the allegations, Staff inappropriately searched a minor while in care and Staff did not prevent a minor from wandering while in care; LPA Karnsrithong conducted confidential interviews and reviewed documentary evidences. There was no sufficient evidence that supports that staff inappropriately searched a minor and staff did not prevent a minor from wandering while in care. Admission Policies on Reasonable Search was provided to clients before enrollment to the facility. Statements were consistent that AWOL/Runaway communication system and policies were implemented when client goes on runaway. There was no corroborating witness. LPA determines that the allegations are unsubstantiated at this time meaning, although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. Exit interview was conducted with Facility Manager and a copy of this report will be provided. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Bernice Karnsrithong 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

report_type: Complaint Investigation

met_with: Brenda Reyes, Facility Manager

complaint_status: unsubstantiated


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Investigation Findings:
13On 08/25/2022 at 12pm, Licensing Program Analyst (LPA) Bernice Karnsrithong arrived at the facility for the purpose of delivering findings for the above complaint investigation. Health and safety risk assessment was conducted upon arriving at the facility. LPA Karnsrithong met with Brenda Reyes, Facility Manager who granted access to the facility. During the investigation of the allegation, Minor was not allowed to receive phone calls; LPA Karnsrithong conducted confidential interviews, conducted on-site inspections, and reviewed documentary evidences. Statements from confidential interviews were consistent that clients are not permitted to receive or make phone calls within the first seven days of admission to the facility. Facility has been cited for California Code of Regulations, Title Division Six, Chapter Article 06. Continuing Requirements Personal Rights: (8) To make and receive confidential telephone calls, unless prohibited by court order. Plan of correction, appeals and exit interview was conducted with Brenda Reyes, Facility Manager SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Bernice Karnsrithong 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 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: ASCEND HEALTHCARE 4FACILITY NUMBER: 198209744

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

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Investigation Findings:
13On 02/26/2025 at 11: AM, LPA Jarmin arrived at Ascend Healthcare 4 to deliver findings on the allegation. LPA met with the Clinical Director and Facility Manager and explained that the investigation concluded on 02/03/2025. During the investigation, LPAs conducted confidential interviews, a health and safety assessment, and reviewed relevant documents. Findings revealed insufficient evidence to substantiate that a staff member engaged in inappropriate contact with a former youth in care. Interviews and records confirmed that the licensee took immediate action when made aware of the issue. The staff member, reassigned pending investigation, voluntarily left before the process was completed and was terminated. The facility followed policies and procedures, including staff training on client interactions and complaints. The allegation is unsubstantiated, meaning there was not enough evidence to support or disprove it. An exit interview was conducted, and a copy of the report will be provided. Amended from 02/26/ Findings. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Enrique M Hernandez LICENSING EVALUATOR NAME: Dennis Jarmin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B This is an official report of an unannounced visit/investigation of a complaint received in our office on 09/08/2023 and conducted by Evaluator Dennis Jarmin COMPLAINT CONTROL NUMBER: 34-CR- FACILITY NAME:ASCEND HEALTHCARE 4FACILITY NUMBER: ADMINISTRATOR:BRITTANY COHENFACILITY TYPE: ADDRESS: LORJEN ROADTELEPHONE: (661) 309- CITY:CANYON COUNTRYSTATE: CAZIP CODE: CAPACITY:6CENSUS: 6DATE: 02/26/ UNANNOUNCEDTIME BEGAN: 11: AM MET WITH:Do not useTIME COMPLETED:01: PM INVESTIGATION FINDINGS: UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Enrique M Hernandez LICENSING EVALUATOR NAME: Dennis Jarmin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 2 of 2

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

met_with: Kathryn Castronovo


summary: Facility Evaluation

raw_content:
Narrative:
On September 30, 2021 at 10:00am, Licensing Program Analyst (LPA) Olivia Rosas conducted a Component II- Face to Face with Ascend Healthcare 4 on Microsoft Teams. The purpose of the meeting was to discuss the Plan of Operation, Program Statement and supporting documents due to the facility opening a Group Home. The Ascend Healthcare 4 is a therapeutic treatment program that's designed to accept "Private Placement's" for a length of 45 - 90 days and will provide care supervision for six (6) clients, ages 12-17 years; ambulatory only. Attendees: Olivia Rosas, Licensing Program Analyst Effie Goldberg/CEO Jaq Waldron, Facility Manager The following matters were discussed: A Fire Safety Inspection Request (Form STD 850) was submitted on 05/26/2021 to the Los Angeles County Fire Department Schools, Churches & Institutions Unit. The fire safety inspection was completed on 06/23/2021 and noted "The facility renders no care to clients. This facility is used for drug and alcohol rehabilitation only. Garages are to be used for stated and vehicle use only, no habitation permitted. The Department is currently not accepting or approving camera/monitoring equipment waivers. Unless prior written licensing agency approval is received and approved no use of cameras/monitoring equipment can be used. PIN 21-03-CRP: Senate Bill 1264 (Committee on Human Services) Chapter 367, Statutes of 2020. Update emergency and disaster preparedness plan. (Continued on LIC809-C) The following is needed for License approval: LIC 309- Administrative organization- Update section 10. LIC308- Designation of Facility Responsibility LIC500- Personnel Form: Update Administrator, Facility Manger LIC 999- Facility Sketch- Update to include pool, label rooms, name rooms be used by staff/residents/clients. LIC610C Emergency Disaster Plan- Update section V. LIC501, LIC503- Personnel Record: Missing CEO, Administrator, Facility Manager with Criminal Clearance Transfer Request for personnel (CEO, Administrator, Facility Manager, Clinical Director, Nurse Manager, Education Manager). Water Safety Certificate for staff is needed because a pool was added Mention of the use of animals for therapeutic therapy Personnel Requirements: Application, Resume, Health Screening (Form LIC503 / TB test) are needed for Administrator, Facility Manager, Clinical Director, Nurse Manager, Education Manager. Section 16- Update CCLD information Section 21- LIC500 update Section 22- Staff Qualifications Section 28- update facility sketches Community Relations and Neighbor Complaints- Update to include dates/times Facility Manger or Administrator is available for neighbors. Include contact information. Each section of the Plan of Operation and Program Statement were reviewed, and LPA discussed the changes and revisions that need to be modified to meet Licensing Standards. LPA Rosas and the facility schedule pre-licensing visit for Wednesday, October 20, 2021 and Comp-III. LPA Rosas provided a copy of LIC Notification of Incomplete Application with items that need to be submitted by 11/29/2021. Exit interview completed and a copy of the report was mail to the Administrator.

met_with: CEO


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Olivia Rosas made an announced inspection to the Ascend Healthcare 4 on 10/19/21 at 9:00am for the purpose of conducting Pre-licensing Inspection. LPA Rosas met with Staff#1(S1), Staff#2(S2), Staff#3(S3) who granted access to the facility and an inspection of the facility was conducted together. The Ascend Healthcare 3 is a therapeutic treatment program that's designed to accept "Private Placement's" for a length of 45 - 90 days and is licensed to provide care supervision for six (6) youths, ages 12-17 years; ambulatory only. Individuals mention in this report are identify on the Confidential Names List (LIC811) dated 10/19/21. The CEO states that there are no guns or weapons on the premises. This is a two-story home with four (4) bedrooms, two (2) staff offices, four (4) bathrooms, living room, kitchen, media room, group room, living room, dining area, outdoor space with basketball court, detach and attach garages, outdoor barn that be used for Equine Therapy farm. LPA inspected the following: The Laundry room: The laundry room is inside of the attach garage adjacent to the kitchen. The laundry detergent is distributed to children individually according to the load of their laundry. Living Room/Dining Room/Kitchen: Observed to be clean and organized; equip with living room furniture. The Kitchen stove is gas operated range. The sharp knives and chemicals are made inaccessible locked in container in the staff office. There are three (3) extra industrial refrigerators in the garage used for extra storage. LPA observed coverage trash cans in the kitchen, bathroom and staff office. LPA observed ample perishable food items in the refrigerator and the pantry is fully stocked with non-perishable food items. LPA observed enough perishable and Non perishable food items for seven (7) days. The applicant will to ensure that three (3) nutritious meals, snacks, and special snacks will be provided to the youth. All disinfectant/ poisons chemicals are properly stored inaccessible. There is a private chef that comes to the facility and prepares all meals for the youth. Report continues on LIC 809-C Bedroom #1 (upstairs): Is vacant. This room has two queen size beds, adequate closet and drawer space. A door chime will be install for balcony access. Bedroom #2 (upstairs): Is used as office space with a daybed. The room will be used as quarantine room if needed. The bedroom has access to the rooftop/patio. A door chime will be install for rooftop access. Bedroom #3 (upstairs): Is vacant. This room has two queen size beds, adequate closet and drawer space. A door chime will be install for balcony access. Bedroom #4 (upstairs): Is vacant. This room has two queen size beds, adequate closet and drawer space. A door chime will be install for balcony access. There is a bathroom in the room. The bedroom has non working fire place. The room has a walk-in closet inside of the bathroom that has attic access that would be locked. Bathrooms: The bathrooms were inspected and found to be clean. LPA observed S1, S2, S3 test the water temperature, bathroom sinks and ensured that all toilets flushed. Two (2) bathrooms are located downstairs. Bathroom#1 is downstairs upon entering the house and Bathroom#2 is by the kitchen. Bathroom#3 is located upstairs and it has shower, sink, and toilet. Bathroom#4 is located inside of Bedroom#4. Staff Office/Medication Room (downstairs): All the children prescribed medications are locked in the staff office and children files are store in a KIPU software system. Staff office is located inside the downstairs floor. LPA observed a large key locked cabinet that stored hygiene supplies, separate containers for medication, various file folders to maintain the youth's records. The First Aid kit has the required items inside (age-appropriate, and scissors, tweezers, thermometer, and gauzes, antiseptic and First Aid Manual Guide. Only staff has access to this room. Staff Office (downstairs): This room will be used for staff. Staff Office/Intake Room (downstairs): This room will be by administration to conduct intakes. All windows were in good condition with screens and blinds. There were no security bars on the windows. LPA observed ample towels and linen closet. Report continues on LIC 809-C Back yard area/outdoors: There is propane grill in good condition also observed to be secure and safe. The outdoor area has detached garage that be used for storage. Two play houses that be locked and only be used as storage. The backyard has basketball court, tennis court, golf, and barn that will be used for horses. At the moment they have no animals. The backyard has construction that per S1 should be completed by the end of the month. Garages: The attached garage is used as storage and is kept locked. The detached garage outside is locked and will be used as storage. LPA observed two storage bins. Storage bins will be used for storage at the time of the inspection they were empty. and will be kept locked. All windows, screens and blinds from the inside and outside of the facility were observed to be in good condition. Although there was not a vehicle to be inspected. S1 ensured that there will be a facility vehicles available to transport the youth to appointment and offsite extra curriculum recreational activities. S1 will provide the make and model of the vehicle once it is the vehicle obtained. The passageways and porches are unobstructed. All posting requirements were met, (food menu, regulations, licenses, emergency disaster plan, Children's Personal Rights, and Ombudsman). The facility has a working telephone and youths can use the telephone unless restricted by court order. The Emergency Evacuation Plan is posted on the walls throughout the facility. There is a wood burning double sided fireplace; operable but not being utilized. The facility uses NEST electronic combined Smoke detector and Carbon Monoxide. On 08/26/2021, facility was informed that currently Community Care Licensing (CCL) are not approving camera waivers. S1 stated the facility has no security cameras installed. The facility currently has no camera waiver or is granted to use video recording cameras. Department will inform facility when the facility can request camera waiver. Fire Clearance granted on 6/22/2020 indicates that "The facility renders no care to clients. This facility is used for drug and alcohol rehabilitation only. Garages are to be used for stated and vehicle use only, no habitation permitted." LPA Rosas inspected and discussed the use of the garages are only to be used for storage or for cars. During inspection the garages are being used as storage. Report continues on LIC 809-C LPA Rosas during the inspection conducted Component III with S1, S2, S3. LPA Rosas was provided with missing documents. LPA Rosas discussed with and advised If any changes or modifications to the program statement or facility physical plant need to be submitted to the Department for review and approval before implementing the new changes. If the facility wants to use detached or attached garages a new fire clearance will need to be requested with a follow up inspection. The facility will submit a safety plan to add a pool to the backyard. During the inspection the facility does not have a pool. The alarm chime sensor waiver request is pending approval from Community Care Licensing Division (CCLD). LPA Rosas recommended for a provisional license based the inspection of the entire physical plant, inside and out. Pre-Licensing administrative conditions are pending review by LPM JoAnne Griffin. Upon receiving probational license the facility will be placement ready. A review of Facility's Personnel Report Summary on 10/18/2021 indicates that no associations have been made to the facility. There were no deficiencies observed or cited at this time. Exit interview was conducted with S2 and a copy of this report was left at the facility.

visit_type: Prelicensing

met_with: Staff#1 (S1)


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Olivia Rosas made an announced inspection to the Ascend Healthcare 4 on 10/19/21 at 9:00am for the purpose of conducting Case Management- Licensee Initiated (Chime Window/Door Waiver). LPA Rosas met with Staff#1(S1), Staff#2(S2), Staff#3(S3) who granted access to the facility and an inspection of the facility was conducted together. The Ascend Healthcare 3 is a therapeutic treatment program that's designed to accept "Private Placement's" for a length of 45 - 90 days and is licensed to provide care supervision for six (6) youths, ages 12-17 years; ambulatory only. Individuals mention in this report are identify on the Confidential Names List (LIC811) dated 10/19/21. The following items were inspected with S1, S2, S3: As indicated on the facility sketch, the facility has a total of four (4) chime alarm sensors installed on the exit glass door in Bedroom#1, Bedroom#2, Bedroom#3 and Bathroom#4 (upstairs) leading to the rooftop/balcony . LPA Rosas and S1, S2, S3 verified the alarm sensors and were operable during the inspection by testing the exit doors. The alarm chime sensor waiver request is pending approval from Community Care Licensing Division (CCLD). There were no deficiencies noted or cited during this inspection. Exit interview was conducted with S2 and a copy of this report was left at the facility


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 01/20/ Licensing Program Analyst (LPA) Bernice Karnsrithong arrived at the facility to conduct a required post licensing inspection. LPA Karnsrithong met with Director of Operations, Jaq Waldron who granted access to the facility and provided the tour. The facility is licensed to provide care and supervision for six (6) youths, ages 12-17 years; ambulatory only. The facility is located in a residential community. The facility provides drug and alcohol rehabilitation and mental health services for male clients only. The facility is gated and fenced in. The front entryway is being used for COVID-19 check in. There are four (4) fire extinguishers throughout the facility and a NEST Fire/Carbon Monoxide Detectors and Alarms throughout the house. During the inspection LPA Karnsrithong has observed the following: Living Room/Common Room: There are three (3) living rooms/common room located downstairs for clients to use. All three living rooms have couches, a table and a rug. This area is used for group activities and therapeutic sessions. The main living room is attached to the kitchen and has a desk, a television, and a book shelf with books and games for clients to use. Outdoor Area: The entire outside area is fenced in. Water and electric shut off valves are located in the front of the house. The gas shut off utility valve is located next to the gate up front. The front lawn has grass and trees. There is a outdoor patio seating with a tree and a swing located in the front yard. The backyard is fenced in and gated. It has a barn with three (3) goats, one (1) sheep and three (3) horses. There is also a chicken coop and a closed in nursery garden in the backyard. There are two (2) outside sheds to be utilized as storage next to the barn. The backyard has a basketball court, tennis court, batting cages and a skate park. The backyard has a covered deck seating that has a propane grill that is secured and safe. (Page 1 of 3) Kitchen/Dining Room Area: The kitchen and dining room area is observed to be clean and well-maintained. A chef was observed preparing meals for the clients in the main kitchen. Menus are posted in the kitchen. LPA observed ample perishable food items in the refrigerator and the pantry is fully stocked with non-perishable food items. There is stove, refrigerator, microwaves, toaster, air fryer, and blender in the kitchen. There is a trash can with a tight fit lid in the kitchen area. There is also a working sink in the main kitchen. Pots, pans, utensils, dishes, and cups are stored in the kitchen. There is a separate kitchen area being used to prepare Kosher meals. It has its own portable stove, microwave, pots, pans, utensils, dishes, and cups. This kitchen has its own sink as well. There is also a nook bar that can be used for dining in the kosher kitchen. The dining room has a long table with ample seating for clients and staff. Office Room: There are three (3) office rooms located downstairs. One office room is being used by administrative staff and is located at the back of the house. It has wall shelf units, an office desk, and chairs. Another office room is being used for therapeutic services. It has couches, coffee table, an office desk, chairs, and a computer. This room has two doors connecting it to the other hallway next to the client downstairs bathroom. One of the doorknobs in this office room is loosed. Another office room is in front of the therapy room. It has a sink, an office desk, chairs, printer, and laptop. It has cabinets that stores medication, hygiene supplies, first aid kit, and medical supplies. It also has a refrigerator that is being used for storing medications if needed. Nursing staff also maintain and monitor the medications, health supplies, and first aid kit. All the children prescribed medications are locked in the staff office and children files are store in a KIPU software system. Staff also uses the cabinets in this room as storage for their personal items. There is a coffee maker inside this office for staff to used. All office rooms are kept locked when not in used. Garages: The attached garage is used as storage for food items and supplies and is kept locked at all times. It has a refrigerators, freezer and a pantry shelf. The laundry room is also located in this garage. There is a detached garage in the facility that is currently being used as an education and art therapy room. There are six (6) computers, tables and chairs for clients to use. There is a driveway outside the detached garage where the facility vehicle is parked at. The facility vehicle is in good working condition. (Page 2 of 3) Bedrooms: There are four (4) bedrooms all located upstairs. One (1) bedroom is currently being used as a quarantine room for COVID and a therapy room if needed. This room has a daybed. All rooms are equipped with full sized beds, adequate closet, and drawer space and adequate lighting. Each room has a patio balcony that has double wooden doors and double screen doors. There is a master bedroom that has a couch and a full-sized bed. The master bedroom has its own bathroom with a toilet, shower, and a tub. The clients are not using the tub and inaccessible. There is walk-in closet that is kept locked in the master bedroom that will be used for storage. There are cabinets located next to the bedrooms being used for storing linens and client's contraband items that is kept locked at all times. Each bedroom has its own facility sketch plan, client schedule, and emergency disaster plan. One bedroom has a broken and ripped screen. A door chime will be installed for patio balcony access. Bathrooms: There are four (4) bathrooms in the facility. Two (2) bathrooms are located downstairs. One is being used by staff only and is kept locked. The staff bathroom has a working toilet and sink. Another bathroom next to the therapy room is used by clients. It has a toilet, sink, and a shower. The shower is not being used. Upstairs there are two (2) bathrooms being used by clients. Both client bathrooms have a shower, double sinks, and a toilet. The faucet in the main client bathroom is loosed and not securely attached. Laundry room: The laundry room is inside of the attach garage adjacent to the kitchen. Laundry supplies are kept in the laundry room. Clients may use the washer and dryer under staff supervision. There are deficiencies cited at this time based on the following regulations: Title Division Section 80088(e)(3): All toilets, hand washing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items. Title Division Section 80087(a): The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. Title Division Section 80088(b): All window screens shall be in good repair and be free of insects, dirt and other debris. Plan of correction was discussed with licensee. Exit interview was conducted and a copy of this report will be provided to the facility via email. (Page 3 of 3)

Deficiencies:
84088(b): Fixtures, Furniture, Equipment, and Supplies

(b) As a condition of licensure, toilets, wash basin, bath and shower fixtures shall, at a minimum, meet the following requirements

met_with: Director of Operations


summary: Facility Evaluation

raw_content:
Narrative:
On 02/04/2022 at 10am, Licensing Program Analyst (LPA) arrived at the facility for the purpose of conducting a Plan of Correction (POC) visit. LPA Karnsrithong met with Facility Manager, Zachary Hale who granted access and tour of the facility. The current census of the facility is four (4). During the visit there were four (4) staff on site. Currently there are two (2) positive cases of COVID-19 during the visit. The clients tested positive on 02/01/2022 and are currently being quarantined. During the visit, LPA Karnsrithong observed that the facility is observing COVID-19 protocols by taking temperatures of all guests and staff coming in to the facility. All staff and clients are wearing surgical masks. There is a COVID-19 sign in at the doorway. LPA Karnsrithong had observed that the bedroom #3 window screened is in good repair. The faucet in the client bathroom upstairs is also in good repair and securely bolted in to the sink. The door knob in the Office/Therapy Room is securely attached and in good repair. The facility has met the requirements for the Plan of Corrections. No deficiencies were cited at this time. Exit interview was conducted with Facility Manager and a copy of this report will be provided to the facility.

met_with: Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On November 3, 2022 at 9: AM, Licensing Program Analyst (LPA) Charmetha White arrived at Ascend Healthcare 4, for the purpose of conducting an Annual/Required inspection. LPA met with Brenda Reyes, Facility Manager and was granted access into the facility. The facility was toured at 10: AM both inside and out. The facility is a private pay therapeutic treatment program licensed to provide care and supervision services for six (6) children, ages 12-17 years old, ambulatory only. The census at the time of the inspection was six (6). The facility is a one story, 4-bedroom, 4-bathroom house which includes multiple Living rooms, Dining room, Kitchen, Laundry area, Medical office, Therapist offices, Administrator office, Equine Therapy farm, Outdoor space, and Garages. The facility is set up as follows: Living rooms: there are a total of 3 (three) living rooms located on the first floor of the home. One living room is located off the kitchen and is furnished with a couch, bookshelf, a mounted television, and contains books and games for the clients. The second living room is located next to the medical office and is furnished with multiple chairs and is used as a group room. The third living room is located near the entrance of the home, it was observed be used as the music room, and it is equipped with ample seating, drums, guitars, and a piano. Dining room: is furnished with a wooden table and eight (8) chairs. Kitchen: is equipped with a 5-burner gas operated stove with a flat top grill, a microwave, refrigerator/freezer, a dishwasher, and a trash compactor. LPA observed the home to have more than a one-week supply of nonperishable foods and 2-day supply of perishable foods. LPA observed menus posted and a food pantry located next to the kitchen. Additionally, there is a separate kitchen area used to prepare Kosher meals, which contains a sink, portable stove, microwave, and separate pots, pans, utensils, dishes, and cups. Laundry area: is adjacent to the kitchen, located inside of the attached garage. The room is equipped with one (1) washer and one (1) dryer. Laundry detergent is distributed to children as needed. Report continued on LIC 808C. Medical office: is next to the group room. The office is equipped with a computer, chair, desk, and a printer. LPA observed the room to have locked cabinets used to store medications, medical supplies, disinfectants, and cleaning supplies. Additionally, the office contains a small refrigerator for medications that require refrigeration and 2 first aid kits. The office is locked and made inaccessible to clients in care. Therapist offices: there are two (2) rooms being used for therapeutic services. The rooms are furnished with a desk, chair, a computer, and a sofa. Administrator office: is located next to the music room and is equipped with a desk, multiple bookshelves, a chair, and contains a closet observed to store extra clothing items. Equine Therapy Farm: has a barn with three (3) goats, one (1) sheep and three (3) horses; and a chicken coop. Outdoor space: The front yard is covered with grass, there is patio seating, and a tree with a swing. The backyard is fenced in and contains equine therapy farm; a closed in nursery garden; two (2) outside sheds which LPA observed to be used as therapy rooms; a basketball court, tennis court, batting cages and a skate park. Additionally, there is covered deck seating and a secured propane grill. Garages: one detached garage observed to be used as a classroom; the room had multiple computers, a table, chairs, and three (3) locked cabinets observed to be used for extra school/classroom supplies. The second garage is attached to the home and was observed to have the laundry area, and an extra refrigerator used by staff, a staff restroom, storage shelves, and two separate therapy offices equipped with desk, chairs, and a sofa. Bedroom #1: is currently being used as a therapy room. Bedroom #2: has two (2) full sized beds, adequate closet, and drawer space and adequate lighting. Bedroom #3: has two (2) full sized beds, adequate closet, and drawer space and adequate lighting. Bedroom #4: is the master bedroom and has two (2) full sized beds, adequate closet, drawer space, adequate lighting, a couch, a non-working fireplace, an attached bathroom, and a walk-in closet that is kept locked at all time. LPA observed the closet to be used for storing linens and client's contraband. Each bedroom has a patio balcony that has double wooden doors and double screen doors. Bathrooms: All bathrooms were checked and found to be in good repair and working order. The hot water temperature was tested and found to be between 105-120 degrees (F). The carbon monoxide and smoke detectors were tested and found to be in working order. First Aid Kit was checked and found to be complete. The facility has 4 regulation fire extinguishers. The facility has a working telephone readily accessible. Report continued on LIC 809C Overall LPA observed the facility to be clean, safe, sanitary and in good repair. The front yard and outdoor space were clean and free of debris. Passageways, stairways, inclines, ramps and open porches were unobstructed. There are no firearms or dangerous weapons in the facility. Temperatures in client rooms and common areas were found to be between 68 - 85 degrees (F). Disinfectants/cleaning solutions and poisons are stored and inaccessible to clients. The facility operates within license conditions and limitations including capacity limitations. LPA discussed and advised the Licensee to ensure the following: Children are supported and encouraged to participate in extracurricular activities. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. All posting requirements for Group Home Licensure and Emergency Plan were met. LPA observed a camera in the living room, dining room, hallways, and outside perimeter. There is no camera waiver on file and facility has not been granted the use of cameras. Facility Manager ensured LPA cameras are not activated. Facility Manager provided LPA with a copy of the Personnel Report (LIC 500). LPA will return at a later time to review client and staff records. There are no deficiencies observed or cited at this during this inspection. An exit interview was conducted with the Facility Manager, and a copy of this report was left at the facility.

visit_type: Annual

met_with: Facility Manager - Brenda Reyes


summary: Facility Evaluation

raw_content:
Narrative:
On May 2, 2024, at 9: AM, Licensing Program Analyst (LPA) C. White made an unannounced visit to Ascend Healthcare 4, for the purpose of conducting a Case Management Inspection. LPA met with the Director of Operations, Jaqueline Marshall Waldron and was granted access to the facility. During this visit, LPA conducted confidential interviews, and reviewed records. LPA requested copies of the following documents: LIC 500, Client Roster, and Client Intake paperwork, medical documentation. Based on interviews and information gathered, this case management needs further investigation. Exit interview was conducted, and a copy of this report was left with the Director of Operations.

met_with: Jaqueline Marshall Waldron - Director of Operations


summary: Facility Evaluation

raw_content:
Narrative:
On November 3, 2025 at 9:00am, Licensing Program Analyst (LPA) Emelyn Sanchez P. arrived at Ascend Healthcare 4, for the purpose of conducting a Required- Year Inspection visit. LPA Sanchez P. met with Brenda Reyes, Regional Operations Manager and was granted access into the facility. LPA Sanchez P. toured the interior and exterior of the facility. The facility is a private pay therapeutic treatment program licensed to provide care and supervision services to six (6) children, ages 12-17 years old, ambulatory only. There is no pool or bodies of water on the premises. The census at the time of the inspection was five (5). The facility is a two story, 4-bedroom, 4-bathroom house which includes multiple Living rooms, Dining room, Kitchen, Garage/Laundry area, Medical office, Therapist offices, Administrator office, Farm, Outdoor space, and Converted Garages. The facility is set up as follows: Living rooms: there are a total of 3 (three) living rooms located on the first floor of the home. One living room is located off the kitchen and is furnished with a couch, bookshelf, a mounted television, and contains books and games for the clients. The second living room is located next to the medical office and is furnished with multiple chairs and is used as a group room. The third living room is located near the entrance of the home, it was observed be used as the music room, and it is equipped with sofa, two chairs, guitars, and a piano. Dining room: is furnished with a wooden table and seven (7) chairs. Report Cont. on LIC 809-C. Pg. 1 of Kitchen: is equipped with a 5-burner gas operated stove, a microwave, refrigerator/freezer, a dishwasher, and a trash can. LPA Sanchez P. observed the home to have more than a one-week supply of nonperishable foods and 2-day supply of perishable foods. LPA Sanchez P. observed menus posted and a food pantry located next to the kitchen. Additionally, there is a separate kitchen area used to prepare Kosher meals, which contains a sink, conventional stove, microwave, mini refrigerator and separate pots, pans, utensils, dishes, and cups. Laundry area: is adjacent to the kitchen, located inside of the attached garage. The room is equipped with one (1) washer and one (1) dryer. Laundry detergent is kept locked and distributed to children as needed. Medical office: is next to the group room. The office is equipped with a computer, chair, desk, and a printer. LPA Sanchez P. observed the room to have locked cabinets used to store medications, medical supplies, and disinfectants. Additionally, the office contains a small refrigerator for medications that require refrigeration and 2 first aid kits. The office is locked and made inaccessible to clients in care. Therapist offices: there are two (2) rooms being used for therapeutic services one upstairs and one downstairs next to the medical office. The rooms are furnished with a desk, chair, a computer, and a sofa. Administrator office: is located next to the music room and is equipped with a desk, multiple bookshelves, a chair, and contains a closet observed to store extra clothing items. Farm: has a barn with three (3) goats, (2) horses, (2) ponies, (2) pigs and a chicken coop. Outdoor space: The front yard is covered with grass, there is patio seating, and a tree with a swing. The backyard is fenced in and contains equine therapy farm; two (2) sheds used to store equipment/storage items, one (1) outside shed which LPA Sanchez P. observed to be used as therapy room; (2) shades used to store farming equipment and hay, a basketball court, mini golf, and a skate park. Additionally, there is covered deck seating and a secured propane grill. Report Cont. on LIC 809-C. Pg. 2 of Garages: one detached garage observed to be used as a classroom/gym space; the room had multiple computers, a table, desks, chairs, and locked cabinets observed to be used for extra school/classroom supplies. The second garage is attached to the home and was observed to have the laundry area, and an extra refrigerator used by staff, and storage shelves. Bedroom #1: is currently being used as a therapy room. Bedroom #2: has two (2) full sized beds, adequate closet, and drawer space and adequate lighting. Bedroom #3: has two (2) full sized beds, adequate closet, and drawer space and adequate lighting. Bedroom #4: is the master bedroom and has two (2) full sized beds, adequate closet, drawer space, adequate lighting, a couch, a non-working fireplace, an attached bathroom, and a walk-in closet that is kept locked at all time. LPA Sanchez P. observed the closet to be used for storing linens and client's contraband. Each bedroom has a patio balcony that has double wooden doors and double screen doors. Bathrooms: All bathrooms were checked and found to be in good repair and working order. The hot water temperature was tested and found to be between 105-120 degrees (F). Overall LPA Sanchez P. observed the facility to be clean, safe, sanitary and in good repair. The front yard and outdoor space were clean and free of debris. Passageways, stairways, inclines, ramps and open porches were unobstructed. There are no firearms or dangerous weapons in the facility. Temperatures in client rooms and common areas were found to be between 68 - 85 degrees (F). Disinfectants/cleaning solutions and poisons are stored and inaccessible to clients.The carbon monoxide and smoke detectors were tested and found to be in working order. First Aid Kit was checked and found to be complete. The facility has 6 (six) fire extinguishers. The facility has a working telephone readily accessible. The facility operates within license conditions and limitations including capacity limitations. LPA discussed and advised the Licensee to ensure the following: Children are supported and encouraged to participate in extracurricular activities. Report Cont. on LIC 809-C. Pg. 3 of Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. LPA Sanchez P. reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. All posting requirements for Group Home Licensure and Emergency Plan were met. LPA was provided with a copy of the Personnel Report (LIC 500) and current client roster. LPA will return at a later time to review client and staff records. There are no deficiencies observed or cited at this during this inspection. An exit interview was conducted with the Brenda Reyes, Regional Operations Manager, and a copy of this report was left at the facility. Pg. 4 of 4


summary: Facility Evaluation

raw_content:
Narrative:
On November 4, 2025 at 9:00am, Licensing Program Analyst (LPA) Emelyn Sanchez P. and Investigator Maria Gliaudys with the Investigations Branch made an unannounced visit to Ascend Healthcare 4 for the purpose of conducting a Case Management- Annual Continuation Inspection. LPA Sanchez P. met with Brenda Reyes, Regional Operations Manager. LPA Sanchez P. was granted access to the facility. The facility keeps staff and client files and documents in digital system called KIPU and Isolved. LPA reviewed the following records during the inspection: Client Records: The program currently has a total of five (5) clients. LPA Sanchez P. reviewed two (2) client records and found each record to meet licensing requirements. Staff Records: The program currently has a total of thirty-five (35) staff. LPA reviewed a total of three (3) staff records and found records to be out of compliance per licensing requirements. LPA Sanchez P. obtained the LIC 500 to verify staff to client ratio. LPA reviewed the Facility Profile and Personnel Report and confirmed that personnel have required criminal record clearance: DOJ, FBI and Child Abuse; which meet licensing requirements. LPA Sanchez P. conducted interviews with two (2) clients and a total of two (2) staff. The following deficiency is being cited for violating California Code of Regulations Title 22, Division Regulation 80066 (a)(10) Personnel Records and 84065 (j)(1) Personnel Requirements . (see page D). An exit interview was conducted, and a copy of this report was left with Brenda Reyes, Regional Operations Manager


summary: Facility Evaluation

raw_content:
Narrative:
On October 22, 2025, Licensing Program Analyst (LPA), Emelyn Sanchez P. made an unannounced visit to Ascend Healthcare 4 for the purpose of conducting a Case Management- Incident visit regarding a sustained injury. LPA Sanchez P. met with Brenda Reyes, Regional Operations Manager to discuss the incident. The special incident report was reported to the Department on 10/12/2025. The incident occurred on 10/01/2025. The incident stated a client's left foot was stepped on by a horse. Based on the information provided, and interviews conducted, it was confirmed that a client did sustain an injury to their foot and received medical attention. However, the incident report was not submitted within a timely manner. The Department has concluded, based on the preponderance of the evidence obtained, that staff did not report the incident upon the occurrence or within the seven days following the occurrence of the incident as required. LPA Sanchez P. informed Brenda Reyes, Regional Operations Manager that the facility would be cited. The following deficiency is being cited for violating California Code of Regulations Title 22, Division Regulation 80061(a)(b)(1)(D) Reporting Requirements. (see page D). Exit interview was completed and a copy of the report and appeal rights were discussed and provided to Brenda Reyes, Regional Operations Manager.


facility_name: ASCEND HEALTHCARE 5

summary: Facility Evaluation

raw_content:
Narrative:
On 10/20/2022 10:30am Licensing Program Analyst (LPA) Rosslyn Gray made an unannounced to ASCEND HEALTHCARE 5 for the purpose to conduct the Prelicensing Inspection. LPA met with the Program Administrator, who granted access into the home, and who provided a tour of the entire physical plant inside and out. The facility is licensed to care for up to six (6) Male and Female children, ages 12-17 years, Ambulatory only. The facility acquired Accreditation of Rehabilitation Facilities Joint Commission valid through 03/20/2024. Staff confirmed that there are no firearms or dangerous weapons in the facility. Group Home Overview: This is a (1) story Group Home facility. There is two (2) car garage that has been converted to a supply storage room. There are total of four (4) operable fireplaces throughout the facility. All are were observed to be secure screens. The Location of the fireplaces are in the medical room, bedroom #1, living room and the group room. There are currently no children in placement. BEDROOMS: All three (3) bedrooms are equipped with comfortable beds, mattresses, linen, blankets and pillows. There are chimes on the exit doors.The Administrator provided a notice of door chimes that are installed in each room.The alarms active to alert when doors open. Bedroom # Currently unoccupied, equipped with a King-size and Queen size bed adequate drawer space (built in shelves and pull-out drawers, and a walk-in bathroom (toiled bidet, large walk-in shower, two (2) sinks and ample storage space. Bedroom #2: Currently unoccupied equipped with a two (2) twin sized beds adequate drawer space (built in shelves) and three (3) open door closets. Bedroom# Currently unoccupied, equipped with two (2) Full size bed and adequate drawer space (built in shelves). BATHROOMS: All were inspected and found to be clean. LPA test the water temperature, bathroom sinks and ensured that all toilets flushed and bathroom #1 has a Bidet. The water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. Bathroom #1 is located inside #1 and #2 is located to the left of the hallway near bedroom #2 and #3. Living Room: is equipped with 2 sectional sofas, three (3) coffee tables, a television and a securely covered fireplace. Dining Room: equipped with a large table with six (6) chairs and ample lighting. Kitchen: LPA observed the monthly/weekly menu posted on the wall. The kitchen. equipped with a double door refrigerator with a bottom freezer, an island stove with two(2)ovens, a six (6) functional gas burners. There is plenty of cabinet space, a locked box for knives and sharp objects. A weekly menu was observed and posted in the kitchen and food service adequate for breakfast, and snacks, lunch and dinner. Meals are prepared by a Private Chef. Laundry area is located near the dining room. The laundry detergent and other cleaning supplies are stored in a locked cabinet about the washer and dryer unit. The locked pantry is located adjacent to the washer and dryer unit. Chemicals and cleaning solutions are kept in locked cabinets located in the laundry room. The Administrator activated the Nest Carbon Monoxide combined smoke detector was observed and functional. LPA observed six (6) fully charged fire extinguishers located throughout the facility. The Clinical Building. This is a large two (2) story. The Clinical office is furnished with two (2) desk and storage closet for the therapist. The group room is equipped with a three (3) sofas, a large chair, a large storage closet a sink, a double burner, bathroom with 1 sink and disconnect steam room. The school is located on the 2nd floor currently under construction and will not be utilize until complete and inspected. The Administrator provided a site construction safety plan. LPA observe listed on the facility sketch as a classroom and cleared by the Fire Inspector on 08/31/2022. Medication Room: Adjacent to bathroom #1 is locked, entry is to the outside left side of building. This room is equipped with office furniture; two (2) desk two (2) chairs, locked med cabinets. LPA observed a large locked First Aid box mounted on the wall, equipped, complete with scissors, tweezers, thermometer, gauzes, antiseptic and 1st Aid Manual. There is also a small refrigerator for storage of client medication that requires refrigeration. The outdoor perimeter area: The large outdoor area space free of obstructions surrounded with several historical trees. The front, and all exits were observed to be free and clear of hazards and obstruction. LPA observed all windows, screens, blinds, and drapes from the inside and outside were observed to be in good condition. There are no security bars on the windows. Sheds: There is shed for lawn care tools, there is Animal Assisting Shed for the Eco therapist. Tennis court, garden area, a three (3) stall stable that houses four (4) goats, two(2) sheep and a one (1) large pig. There is a composting bin. Pool area: The is a eight feet (8) swimming pool and a shed that has a pool pump and pool supplies that meets regulations. Located in the backyard, there is a fenced and gated pool on the premises that meets regulations. Licensee will ensure that individual supervising children in the pool area is Water Safety trained. Facility appears to be clean, safe, sanitary, and in good repair. There is Koi Pond located at the entrance of the facility inspected and with an approved net covering and a Jacuzzi located near the Clinical Building. The Administrator displayed were the gas shut-off valves are located at the end of driveway and water shut-off valve located outside back of the facility near the Medication room. All posting requirements and Emergency Plan were observed. Children will be accorded personal rights.The grievance Procedure and Personal Rights; are posted on the wall. Children are not restricted to make phones calls to family and or authorized representative. Client will be permitted to make phones calls and stored on electronic program. The Administrator will ensure to utilized the Unusual Incident Report LIC 624, and LIC 624LE to document incidents. Clients Records: Child's Needs and Services plans will be electronically stored in the facilities online Portal with Kipuworks.com electronically stored. Staff Records are electronically stored in the ISolved system. LPA thoroughly reviewed three (3) the records of active primary staff; Program Administrator, Director of Facilities and the Facility Manager, There were no deficiencies cited at this time. LPA concluded the Pre license Inspection. An Exit interview was conducted, and a copy of this report was left at the facility with the Program Administrator

met_with: ADMINISTRATOR


summary: Facility Evaluation

raw_content:
Narrative:
On March 23, 2023, at 9: AM, Licensing Program Analyst (LPA) Charmetha White made an unannounced visit to Ascend Healthcare 5, for the purpose of conducting a Post Licensing Inspection. LPA met with Brenda Reyes, Facility Manager who granted access to the facility and together a tour of the entire interior and exterior physical plant was conducted. The facility is a private pay Group Home running a therapeutic treatment program licensed to provide care and supervision services for up to six (6) male and female children, ages 12-17 years old, ambulatory only. The facility acquired a Rehabilitation Facilities Joint Commission Accreditation which is valid through 03/20/2024. Staff confirmed there are no firearms or dangerous weapons on the premises. The census at the time of the inspection was six (6). The Group Home is set up as follows: This is a single-story, three (3) bedrooms, 2 bathrooms house which includes: Living room, Dining room, Kitchen, Laundry area, Medication room, Detached Clinical Building, Equine Therapy farm, Outdoor space, and a Detached Garage. Living Room: is equipped with 2 sectional sofas, three (3) coffee tables, a television and a securely covered fireplace. Dining Room: is equipped with a large table with six (6) chairs. Kitchen: is equipped with a double door refrigerator/freezer, six (6) burner gas operated stove (all burners were operable at the time of the inspection), two (2) ovens, a dishwasher, a trash compactor, a microwave, and a coffee machine. LPA observed the kitchen to have pots, pans, utensils, dishes, cups, plenty of cabinet space, the weekly menu was posted, and the knives and sharps were in a locked kitchen cabinet to the left of the refrigerator. There was an adequate supply of food and meals are prepared offsite by a Private Chef and brought over to the home. Laundry area is located along the hall leading to the side of the house and includes one (1) washer and one (1) dryer. Laundry detergent is kept locked in cabinets above the washer and dryer. Additionally, this area has an exit door which opens to the side of the facing the stairs of the clinical building. There is also a separate small room adjacent to the washer and dryer, which remains locked at all times. LPA observed the room to have a sink and it is used to store extra supplies, chemicals, and cleaning solutions. Report continued on LIC 809C (Page 1 of 3). Medication Room: is located next to bathroom #1 and is only accessible through an entry at the back of the house. The room is equipped with two (2) desks, two (2) chairs, locked cabinets that store medication and medical supplies. There is a First Aid box mounted on the wall, that LPA observed to be equipped with scissors, tweezers, gauzes, and antiseptic, and a digital thermometer. The room also contains a small locked refrigerator to storage client medication that requires refrigeration. The Clinical Building. This is a two-story building located next to the house. The first floor is used as a classroom which is equipped six (6) desks, computers, chairs, a long table, cabinets observed to be used for extra school/classroom supplies, and a bathroom. The bathroom contains a sink and a toilet. There is also a separate office next to the classroom. This room is used by the therapist as a group room and contains a desk, chair, a sofa, and a closet. The second floor is equipped with a conference desk, multiple chairs, storage closets, and a small bathroom. The bathroom contains a toilet, a sink, and a door which opens to an unfinished closet. Equine Therapy Farm: has a barn with four (4) goats, two (2) sheep, two (2) horses, one (1) pig, and a chicken coop. Outdoor space: contains a Koi pond, pool/jacuzzi, and a tennis/basketball court. LPA observed the pool area to fenced and gated to meet regulations. There is also a shed in the backyard that contains the pool pump and pool supplies. The Koi Pond is located at the entrance of the house and was equipped with an approved net covering. Detached Garage: LPA observed the garage to be used for extra storage. Bedrooms: Bedroom #1: is equipped with one (1) King-size bed and one (1) Queen size bed. The room has adequate drawer space, built in shelves, pull-out drawers, double patio doors leading to the side of the house, and a walk-in bathroom. The bathroom has double sinks, a section containing a toilet and a bidet, and a separate section containing a walk-in shower. LPA observed a walk-in closet located in the bathroom which remains locked at all time and it is used for storage. Bedroom #2: is equipped with two (2) Twin sized beds and has adequate drawer space, three closets, and built in shelves. Bedroom#3 is equipped with two (2) Full size beds and has adequate drawer space and built in shelves. LPA observed all three (3) bedrooms to have comfortable mattresses, linens, blankets, and pillows. Each room has door chimes installed on the exit doors tht sounds an alarm when the door opens. Bathrooms: Bathroom #1: is located inside of bedroom #1. Bathroom #2: is located along the hallway catacorner to the kitchen and near bedroom #1 and #2. Report continued on LIC 809C (Page 2 of 3). Additionally, there are two (2) other bathrooms located in the detached clinical building. All bathrooms were inspected and found to be in good repair and working order. The hot water temperature was tested and found to be between 105-120 degrees (F). The carbon monoxide and smoke detectors were tested and found to be in working order. First Aid Kit was checked and found to be complete. The facility has six (6) regulation fire extinguishers. The facility has a working telephone readily accessible. Temperatures in client rooms and common areas were found to be between 68 - 85 degrees (F). Disinfectants/cleaning solutions and poisons are stored and inaccessible to clients. LPA observed the facility to be clean, safe, sanitary and in good repair. The outdoor spaces were clean and clear of hazards. Passageways, open porches, and all exits were observed to be unobstructed. There were no security bars on the windows. Licensee ensures that individuals supervising children in the pool area is Water Safety trained. The facility operates within license conditions and limitations including capacity limitations. LPA discussed and advised the Licensee to ensure the following: Children are afforded their Personal Rights. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. All posting requirements for Group Home Licensure, including the Emergency Plan, and grievance procedure were met and posted on the wall. The LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. Licensee will ensure to utilize the Unusual Incident Report LIC 624, and LIC 624LE to document incidents. Facility Manager provided LPA with a copy of the Personnel Report (LIC 500). LPA will return at a later time to review client and staff records. There are no deficiencies observed or cited at this during this inspection. Exit interview was conducted with the Facility Manager, and a copy of this report was left at the facility. (Page 3 of 3).


summary: Facility Evaluation

raw_content:
Narrative:
On October 30, 2023, at 10: AM, Licensing Program Analyst (LPA) Charmetha White made an unannounced visit to Ascend Healthcare 5, for the purpose of conducting an Annual/Required Inspection. LPA met with Brenda Reyes, Facility Manager who granted access to the facility and together a tour of the entire interior and exterior physical plant was conducted. The facility is licensed to provide care and supervision services for up to six (6) male and female children, ages 12-17 years old, ambulatory only. The facility's Rehabilitation Facilities Joint Commission Accreditation is valid through 03/20/2024. There a no firearms or dangerous weapons on the premises. The census at the time of the inspection was six (6). The Group Home is set up as follows: This is a single-story, three (3) bedrooms, 2 bathrooms house which includes: Living room, Dining room, Kitchen, Laundry area, Medication room, Detached Clinical Building, Equine Therapy farm, Outdoor space, and a Detached Garage. Living Room: is equipped with sectional sofas, coffee tables, a television and a securely covered fireplace. Dining Room: is equipped with a large table with six (6) chairs. Kitchen: is equipped with a double door refrigerator/freezer, a built-in six (6) burner gas operated stove (all burners were operable at the time of this inspection), two (2) ovens, a dishwasher, a trash compactor, a microwave, and a coffee machine. LPA observed the kitchen to have pots, pans, utensils, dishes, cups, and plenty of cabinet space. LPA observed the knives and sharps locked in a kitchen cabinet located to the left of the refrigerator and the weekly menu was posted. The facility had adequate perishable and non-perishable food on-site and meals are prepared offsite by a Private Chef and brought over to the home. Laundry area is located along the hall and includes one (1) washer and one (1) dryer. Laundry detergent is kept locked in cabinets above the washer and dryer. Additionally, this area has an exit door that opens to the side of the home. There is a separate small room adjacent to the washer and dryer, which is locked at all times. LPA observed the room to have a sink and it is used to store extra supplies, chemicals, and cleaning solutions. Medication Room: is adjacent to bathroom #1 and is only accessible through an entry at the back of the house. The room is equipped with a desk, chairs, a locked cabinet that stores medication and medical supplies and a small, locked refrigerator to store medication requiring refrigeration. LPA observed the room to have a First Aid box mounted to the wall. Report continued on LIC 808C (page 1 of 3) The Clinical Building. This is a separate two-story building adjacent to the main house. The first floor is used as a classroom that is equipped with six (6) desks, computers, chairs, a long table, cabinets observed to be used for extra school/classroom supplies, and a bathroom. The bathroom contains a sink and a toilet. There is a separate office next to the classroom, that is used by the therapist as a group/therapy office. The office contains a desk, chairs, a sofa, a closet which is used for storage, and a small bathroom. The bathroom contains a toilet, a sink, and a shower. The second floor is equipped with a conference desk, multiple chairs, storage closets, and a small bathroom. The bathroom contains a toilet, a sink, and a door which opens to an unfinished closet. Equine Therapy Farm: has a barn, goats, sheep, horses, a pig, and a chicken coop. Outdoor space: contains a Koi pond near the front entrance and is equipped with an a net covering, a pool/jacuzzi on the side of the home which is fenced and gated to meet reguluations, and a tennis/basketball court in the back of the home. Detached Garage: LPA observed the garage to be used for extra storage. Small shed: located behind the clinical building which is used to store maintenance supplies. Bedrooms: Bedroom #1: is equipped with one (1) King-size bed and one (1) Queen size bed. The room has adequate drawer space, built in shelves, and pull-out drawers. The room has double patio doors leading to the side of the house, and a walk-in bathroom. The bathroom has double sinks, a toilet and a bidet, and a separate enclosure containing a walk-in shower. There is a walk-in closet located in the bathroom that is used for storage and remains locked at all times. Bedroom #2: is equipped with two (2) Twin sized beds. The room has adequate drawer space, three closets, and built in shelves. Bedroom#3 is equipped with two (2) Full size beds. The room has adequate drawer space and built in shelves. LPA observed all three (3) bedrooms to have comfortable mattresses, linens, blankets, pillows, and adequate lighting. Bathrooms: Bathroom #1: is located inside of bedroom #1. Bathroom #2: is located along the hallway near the the kitchen and bedroom #1 and #2. Report continued on LIC 809C (page 2 of 3) Additionally, there are two (2) other bathrooms located in the detached clinical building. All bathrooms were inspected and found to be in good repair and working order. The hot water temperature was tested and found to be between 105-120 degrees (F). The carbon monoxide and smoke detectors were tested and found to be in working order. First Aid Kit was checked and found to be complete. The facility has six (6) regulation fire extinguishers. The facility has a working telephone readily accessible. Temperatures in client rooms and common areas are maintained by a central air and heating system and the home was found to be between 68 - 85 degrees (F). Disinfectants/cleaning solutions and poisons are stored and inaccessible to clients. LPA observed the facility to be clean, safe, sanitary and in good repair. The outdoor spaces were clean and clear of hazards. Passageways, open porches, and all exits were observed to be unobstructed. There were no security bars on the windows. Licensee ensures that individuals supervising children in the pool area is Water Safety trained. The facility operates within license conditions and limitations including capacity limitations. All posting requirements for Group Home Licensure, including the Emergency Plan, Personal Rights, and Grievance Procedures were met and posted on the wall. LPA discussed the following: Children are afforded their Personal Rights. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. LPA reiterated the importance of reporting and submitting Incident Reports, Law Enforcement contact, and reporting all changes within the facility to Community Care Licensing and any other appropriate agencies. The Administrator will ensure the Unusual Incident Report LIC 624, and LIC 624LE forms are utilized to document incidents. Clients Records are electronically stored in the facilities online Portal with Kipuworks.com Staff Records are electronically stored in the ISolved system. Facility Manager provided LPA with a copy of the Personnel Report (LIC 500). LPA will return at a later date to review client and staff records. There are no deficiencies observed or cited at this during this inspection. Exit interview was conducted with the Facility Manager, and a copy of this report was left at the facility. (Page 3 of 3)

met_with: Brenda Reyes - Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 10/31/2023 at 9: AM, Licensing Program Analyst (LPA) C. White, made an announced visit to Ascend Healthcare 5, for the purpose of conducting a Case Management Annual Continuation Inspection. LPA met with Facility Manager, Brenda Reyes. LPA was granted access to the facility and provided the requested information. The facility keeps clients records electronically stored in an online system call KIPUERM and staff Records are electronically stored in the ISolved system. LPA reviewed the following records during the inspection: Client Records: The program currently has a total of six (6) clients. LPA reviewed all six client records and found each record to meet required regulations. Staff Records: The program currently has a total of fourteen (14) staff. LPA reviewed a total of five (5) staff records and confirmed files contained staff qualifications, current CPR/First Aid cards, health screening, and TB test results. LPA obtained the LIC 500 to verify Staff to Client ratio. LPA reviewed the Facility Profile and Personnel Report and confirmed that personnel have required criminal record clearance: DOJ, FBI and Child Abuse; which meet qualification. LPA conducted interviews with five (5) clients and a total of two (2) staff. This inspection included an overview of required Core Services and Supports and based upon inspection of facility records and interviews of staff and clients. Licensee is meeting all requirements. There were deficiencies cited per California Code of Regulations and Interim Licensing Standards. Exit interview was conducted, Appeal Rights and a copy of this report was given to the Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On November 20, 2024, at 10: AM, Licensing Program Analyst (LPA) C. made an unannounced visit to Ascend Healthcare 5, for the purpose of conducting an Annual/Required Inspection. LPA met with Brenda Reyes, Facility Manager who granted access to the facility and together a tour of the entire interior and exterior physical plant was conducted. The facility is licensed to provide care and supervision services for up to six (6) male and female children, ages 12-17 years old, ambulatory only. There a no firearms or dangerous weapons on the premises. The census at the time of the inspection was six (6). The Group Home is set up as follows: This is a single-story house that includes three (3) bedrooms, 2 bathrooms, a living room, dining room, kitchen, laundry area, and a detached two (2) car garage. The home also includes a medication room, a detached clinical building, an equine therapy farm, and outdoor space. Living Room: is equipped with sofas, coffee tables, a mounted television and a covered fireplace. Dining Room: is equipped with a large table with six (6) chairs. Kitchen: is equipped with a double door refrigerator with a bottom freezer, an island stove with six (6) functional gas burners and two (2) ovens, a dishwasher, a trash compactor, a microwave, a coffee machine, an electric ice machine, pots, pans, eating utensils, dishes, and cups. LPA observed the knives and sharps locked in toolbox and kept in a locked kitchen cabinet located to the left of the refrigerator. LPA observed the food menu posted. The facility had the required 2 days of perishable/1 week of non-perishable food supply on the premises and meals are prepared offsite by a Private Chef and brought over to the home. Laundry Area: is adjacent to the kitchen and includes one (1) washer and one (1) dryer. Laundry detergent and cleaning supplies are kept locked in cabinets located this area. The laundry area has an exit door that opens to the side of the home. Additionally, the laundry area has a pantry that is kept locked at all times. LPA observed the pantry to have a sink and it is used to store additional chemicals and cleaning solutions. Detached Garage: LPA observed the garage to be used for extra storage. Report continued on LIC 809C (Page 1 of 3). Medication Room: is only accessible through an entry at the back of the house and is kept locked when not in use. The room is equipped with a desk, chairs, a locked medication cabinet which stores medication, medical supplies, and first aid supplies. The room has a small locked refrigerator to store medication requiring refrigeration. The room has an additional mounted First Aid box complete with tweezers, scissors, gauzes, and antiseptic. Clinical Building. This is a separate two-story building adjacent to the main house. The first floor is used as a classroom that is equipped with six (6) desks, computers, and chairs. The room has a large storage closet which remains locked at all times. LPA observed the cabinet to have extra school/classroom supplies. The room contains a bathroom with a sink and a toilet. There is a separate office next to the classroom, used by the therapist as a group/therapy office. The office contains a desk, chairs, a sofa, a closet which used for storage. The second floor is equipped with a conference desk, multiple chairs, storage closets, and a small bathroom. The bathroom contains a toilet, a sink, and a door which opens to an unfinished closet. Equine Therapy Farm: has a barn, goats, sheep, horses, a pig, and a chicken coop. Outdoor space: the home has a large outdoor space that contains a Koi pond near the front entrance and is equipped with an a net covering; a pool on the side of the home which is fenced and gated to meet regulations; a jacuzzi equipped with a net covering, and a tennis/basketball court in the back of the home. Small shed: located behind the clinical building which is used to store maintenance supplies. Bedrooms: Bedroom #1: is equipped with one (1) King-size bed and one (1) Queen size bed. The room has adequate drawer space, built in shelves, and pull-out drawers. The room has a walk-in bathroom. The bathroom has double sinks, a toilet and a bidet, and a separate enclosure containing a walk-in shower. There is a walk-in closet located in the bathroom that is used for storage and remains locked at all times. Bedroom #2: is equipped with two (2) Twin sized beds. The room has adequate drawer space, three closets, and built in shelves. Bedroom#3 is equipped with two (2) Full size beds. The room has adequate drawer space and built in shelves. LPA observed all three (3) bedrooms to have linens, blankets, pillows, and working lights. Bathrooms: Bathroom #1: is located inside of bedroom #1. Bathroom #2: is located along the hallway near the the kitchen and bedroom #1 and #2. Report continued on LIC 809C (Page 2 of 3). Additionally, there are two (2) other bathrooms located in the detached clinical building. All bathrooms were inspected and found to be in good repair and working order. The hot water temperature was tested and found to be between 105-120 degrees (F). The carbon monoxide and smoke detectors were tested and found to be in working order. The facility has six (6) regulation fire extinguishers. The facility has a working telephone readily accessible. Temperatures in client rooms and common areas are maintained by a central air and heating system and the home was found to be between 68 - 85 degrees (F). LPA observed the facility to be clean, safe, sanitary and in good repair. The outdoor spaces were clean and clear of hazards. Passageways, open porches, and all exits were observed to be unobstructed. There were no security bars on the windows. Licensee ensures that individuals supervising children in the pool area is Water Safety trained. The facility operates within license conditions and limitations including capacity limitations. All posting requirements for Group Home Licensure, including the Emergency Plan, Personal Rights, and Grievance Procedures were met and posted on the wall. LPA discussed the following: Children are afforded their Personal Rights. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. LPA reiterated the importance of reporting and submitting Incident Reports, Law Enforcement contact, and reporting all changes within the facility to Community Care Licensing and any other appropriate agencies. The Administrator will ensure the Unusual Incident Report LIC 624, and LIC 624LE forms are utilized to document incidents. Clients Records are electronically stored in the facilities online Portal with Kipuworks.com Staff Records are electronically stored in the ISolved system. Facility Manager provided LPA with a copy of the Personnel Report (LIC 500) and a current Client Roster (LIC 9020). LPA will return at a later date to review client and staff records. There are no deficiencies observed or cited at this during this inspection. Exit interview was conducted with the Facility Manager, and a copy of this report was left at the facility. (Page 3 of 3).


summary: Facility Evaluation

raw_content:
Narrative:
On November 17, 2025, at 9:30am Licensing Program Analyst (LPA) Emelyn Sanchez P. made an unannounced visit to Ascend Healthcare 5 for the purpose of conducting an Annual/Required Inspection visit. LPA Sanchez P. met with Brenda Reyes, Regional Operations Manager who granted access to the facility. LPA Sanchez P. toured the interior and exterior of the facility. The facility is licensed to provide care and supervision services for up to six (6) children, ages 12-17 years old, ambulatory only. There is a swimming pool on the premises which meets licensing regulations. The census at the time of the inspection was six (6). The facility is a single-story house that includes three (3) bedrooms, 2 bathrooms, a living room, a dining room, kitchen, laundry area, and a detached two (2) car garage. The home also includes a medication room, a detached clinical building, a farm, and outdoor space. The facility is set up as follows: Living Room: is furnished with sectional sofas, a coffee table, a mounted television and a covered fireplace. Dining Room: is equipped with a round table with seven (7) chairs. Kitchen: is equipped with a double door refrigerator with a bottom freezer, an island/stove with six (6) functional gas burners and two (2) ovens, a dishwasher, a non-operating trash compactor, a microwave, a coffee machine, an electric ice machine, pots, pans, eating utensils, dishes, and cups. LPA Sanchez P. observed the knives and sharps locked in a toolbox and kept in a locked kitchen cabinet located to the left of the refrigerator. Report Cont. on LIC 809-C. Pg. 1 of LPA Sanchez P. observed the food menu to be posted. The facility had the required nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days on the premises. LPA Sanchez P. was informed that meals are prepared offsite by a Private Chef and brought over to the home. Laundry Area: is adjacent to the kitchen and includes one (1) washer and one (1) dryer. Laundry detergent and cleaning supplies are kept locked in cabinets located in this area. The laundry area has an exit door that opens to the side of the home. Additionally, the laundry area has a room that is kept locked at all times. LPA Sanchez P. observed the room to have a sink and it is used to store additional chemicals and cleaning solutions. Detached Garage: LPA Sanchez P. observed the garage to be used as a maintenance office space and for extra storage. Medication Room: is only accessible through an entry at the back of the house and is kept locked when not in use. The room is equipped with a desk, chair, locked medication cabinets which store medication, medical supplies, and first aid supplies. The room has a small locked refrigerator to store medication requiring refrigeration. The room has an additional complete mounted First Aid box. Clinical Building: This is a separate two-story building adjacent to the main house. The first floor is used a classroom that is equipped with desks, computers, and chairs. The room has a large storage closet which remains locked at all times. LPA Sanchez P. observed the cabinets to have extra school/classroom supplies. The room contains a bathroom with a sink and a toilet. There is a separate office next to the classroom, used by the therapist as a group/therapy office. The office contains a desk, chair, a sofa, a closet which is used for storage. The second floor is equipped with a conference desk, multiple chairs, storage closets, and a small bathroom. The bathroom contains a toilet, a sink, and a door which opens to a locked closet. Outdoor Space: the home has a large outdoor space that contains a Koi pond near the front entrance and is equipped with an a net covering; a pool on the side of the home which is fenced and gated to meet licensing regulations; a jacuzzi equipped with a net covering, and a tennis/basketball court in the back of the home. Report Cont. on LIC 809-C. Pg. 2 of Farm: has a barn with four (4) goats, three (3) horses, one (1) pig and a chicken coop. Small shed: located behind the clinical building which is used to store maintenance supplies. Bedrooms: Bedroom #1: is equipped with one (1) king-size bed and one (1) queen size bed. The room has adequate drawer space, built in shelves, and pull-out drawers. The room has a walk-in bathroom. The bathroom has double sinks, a toilet and a dubai, and a separate enclosure containing a walk-in shower. There is a walk-in closet located in the bathroom that is used for storage and remains locked at all times. Bedroom #2: is equipped with two (2) twin sized beds. The room has adequate drawer space, three closets, and built in shelves. Bedroom#3: is equipped with two (2) full size beds. The room has adequate drawer space and built in shelves. LPA Sanchez P. observed all three (3) bedrooms to have linens, blankets, pillows, and working lights. Bathrooms: Bathroom #1: is located inside of Bedroom #1. Bathroom #2: is located along the hallway near the kitchen and Bedroom #1 and #2. Additionally, there are two (2) other bathrooms located in the detached clinical building. All bathrooms were inspected and found to be in good repair and working order. The hot water temperature was tested and found to be between 105-120 degrees (F). The carbon monoxide and smoke detectors were tested and found to be in working order. The facility has six (6) regulation fire extinguishers. The facility has a working telephone readily accessible. Temperatures in client rooms and common areas are maintained by a central air and heating system and the home was found to be between 68 - 85 degrees (F). Report Cont. on LIC 809-C. Pg. 3 of Overall LPA Sanchez P. observed the facility to be clean, safe, sanitary and in good repair. The front yard and outdoor spaces were clean and free of debris. Passageways, open porches, and all exits were observed to be unobstructed. Licensee ensures that individuals supervising children in the pool area are Water Safety trained. The facility operates within license conditions and limitations including capacity limitations. All posting requirements for Group Home Licensure, including the Emergency Plan, Personal Rights, and Grievance Procedures were met and posted on the wall. LPA Sanchez P. discussed the following: Children are accorded their Personal Rights. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. LPA Sanchez P. reiterated the importance of reporting and submitting Incident Reports, Law Enforcement contact, and reporting all changes within the facility to Community Care Licensing and any other appropriate agencies. The Administrator will ensure the Unusual Incident Report LIC 624, and LIC 624LE forms are utilized to document incidents. LPA Sanchez P. was provided with a copy of the Personnel Report (LIC 500) and Client Register (LIC 9020). LPA will return at a later date to review client and staff records. There are no deficiencies observed or cited at this time during this inspection. An exit interview was conducted with Brenda Reyes, Regional Operations Manager, and a copy of this report was left at the facility. Pg. 4 of 4


summary: Facility Evaluation

raw_content:
Narrative:
On November 18, 2025 at 9:20am, Licensing Program Analyst (LPA) Emelyn Sanchez P. made an unannounced visit to Ascend Healthcare 5 for the purpose of conducting a Case Management- Annual Continuation Inspection visit. LPA Sanchez P. met with Brenda Reyes, Regional Operations Manager and Jaqueline M. Waldron, Administrator. LPA Sanchez P. was granted access to the facility. The facility keeps staff and client files and documents in digital system called KIPU and Isolved. LPA reviewed the following records during the inspection: Client Records: The program currently has a total of six (6) clients. LPA Sanchez P. reviewed two (2) client records and found each record to meet licensing requirements. Staff Records: The program currently has a total of twenty-six (26) staff. LPA reviewed a total of three (3) staff records and confirmed files contained staff qualifications, current CPR/First Aid cards, required training hours, health screening, and TB test results. LPA Sanchez P. obtained the LIC 500 to verify staff to client ratio. LPA reviewed the Facility Profile and Personnel Report and confirmed that personnel have required criminal record clearance: DOJ, FBI and Child Abuse; which meet licensing requirements. LPA Sanchez P. conducted interviews with two (2) clients and a total of three (3) staff. Per California Code Regulations, TITLE 22, DIVISION 6, CHAPTERS 5 no deficiencies were cited. An exit interview was conducted, and a copy of this report was left with Brenda Reyes, Regional Operations Manager


facility_name: ASCEND HEALTHCARE 7

summary: Facility Evaluation

raw_content:
Narrative:
On April 9, 2024, Licensing Program Analyst (LPA) C. White arrived at Ascend Healthcare #7 for the purpose of conducting a Group Home Pre-licensing inspection. LPA met with Director of Operations, Jaqueline Marshall Waldron and Administrator, Brenda Reyes who granted access to the facility and provided the tour. Ascend Healthcare #7 is a therapeutic treatment program designed to accept "Private Placement's" for a length of 45 to 90 days. The facility will be licensed to provide care and supervision for six (6) children, ages 12-17 years old; ambulatory only. Currently the census is zero (0). The facility is set up as follows: This is a single-story home. There are three (3) bedrooms, five (5) bathrooms, living room, dining room, kitchen, a group room, a classroom, medication room, a clinical room, two (2) offices, laundry room, an attached garage, and outdoor/backyard area. Living room: has a sectional sofa, operational gas burning fireplace equipped with security glass, and a door leading to the patio and backyard. Dining room: Is equipped with a wooden table with eight (8) chairs. Kitchen: Is equipped with refrigerator/freezer, a gas stove with six (6) working burners, two (2) microwaves, dishwasher, and a pantry. LPA observed a covered trash can with a mechanical foot closing device. There were ample plates, cups, and eating utensils. Sharp knives will be stored in a locked drawer in the medical room. LPA observed ample non-perishable food items and snacks in pantry. The Applicant will ensure that three (3) nutritious meals and snacks will be provided to the children in care. Group Room: One group room has a mirrored wall, eight (8) chairs, an operational gas burning fireplace equipped with security glass, and wall to floor windows looking out to the backyard. Classroom: The has six (6) desks, chairs, computers, and an operational electric fireplace equipped with security screen. The room also has an attached bathroom. Medication room: was observed to have a standing locked cabinet for use to store PRN medications and separate bins for prescribed medications for individual children; multiple locked and labeled cabinets; a complete First Aid kit; a small locked refrigerator for use to store medication. Report continued on LIC 809C. (Page 1 of 3). The following was discussed with the facility Administrator: Children will be accorded personal rights. Children in care will be supported, encouraged to participate in extracurricular activities. Children in care will be able to contact the licensing agency. Children will be supervised & protected at all times. Children will be accorded dignity in personal relationships with others in the home. Children will not be restricted in telephone use except by court order. Applicant will ensure to have written authorization to obtain medical and dental care. Applicant will ensure to have personal rights forms in children's files. Applicant acknowledges abuse reporting requirements. Staff working in the facility will have DOJ/FBI criminal record clearances, and Child Abuse Index Checks. Facility will operate within license conditions & limitations including capacity limit. Facility meets posting requirements. There were no deficiencies cited at this time. LPA concluded the Pre license Inspection. An Exit interview was conducted, and a copy of this report was left at the facility with the Program Administrator. (Page 3 of 3). Clinical room: has a desk, chair, and two (2) chairs. The room has a door that opens to the backyard. Offices: are located near the classroom. Each room has two (2) chairs. Laundry room: is located near the medication room. The room is equipped with one (1) washer, one (1) dryer, and a sink. This room also has a door that opens to the garage. Attached Garage: is used to store disinfectants and extra cleaning supplies, which will be made inaccessible to children in care. Bedrooms: There are three (3) bedrooms. Bedroom #1 is equipped with two (2) twin beds; Bedroom #2 is equipped with two (2) queen size beds; Bedroom #3 is equipped with two (2) twin beds. All rooms have adequate closet and drawer space and working lights. Bathrooms: There are five (5) bathrooms. One bathroom is located in the classroom; one bathroom is located in bedroom #3; one bathroom is located next to bedroom #2; one bathroom is located in the hallway to the left of the entrance; and one bathroom is located next to the medical room. All bathrooms have a toilet, sink, and a shower. Bathrooms were found to be clean and in working order. Outdoor Area: The entire property is fenced in. Water and electric shut off valves are located in the front of the house. The gas shut off utility valve is located next to the gate up front. The front lawn has grass and trees. The backyard has a gated pool and jacuzzi that meet regulations. There is an outside seating area that contains a gas grill, a small refrigerator, a table with eight (8) chairs, and a sofa. There is an enclosed garden, a chicken coop, a shed used to store animal food and supplies, and a large, detached garage which will be used for storage. LPA observed the home to have ten (10) regulation fire extinguishers. The smoke detectors and carbon monoxide alarm were tested and found to be operating properly. There are no security bars on the windows. There are no firearms or dangerous weapons in the home. The gas shut off valve is located in the back of the house, the water shut off valve is in the front of the home, and the electric shut off panel is located in the attached garage. Facility appears to be clean, safe, sanitary, and in good repair. Passageways and porch were clean and in good repair. The front and back yard were free of debris and hazardous material. Report continued on LIC 809C. (Page 2 of 3).

met_with: Administrator - Brenda Reyes