summary: Facility Evaluation

raw_content:
Narrative:
On 02/15/2024 at 11: AM Licensing Program Analyst (LPA) Christine Wilson, arrived at the above facility for the purpose of conducting Pre-Licensing inspection. A health and risk assessment was conducted. LPA Wilson met with the Prospective Licensee Ivery Harris (S1 )and Sherri Parker (S2) who granted access to the facility. Prospective Licensee (S1 and S2) provided a walk-through of the facility. Home also consists of two car garage. Home cannot be accessed through garage. The facility is seeking a Small Family Home license to provide care and supervision for three (3) clients, ages 3-17, ambulatory only. The following was observed during the inspection:This is a unit located on the second floor,located in a apartment community. Home is located at Alder Dr. Unit 201 consists of: LPA Wilson observed four (4) hard wired interconnected combined smoke detector and carbon monoxide detectors; tested to be operable. Garage: This area is equipped for two (2) vehicles. Living Room: The living room is fully furnished. The living room is a common area with seating for five (5), cabinet, television and two area rugs. All furniture is in new condition. LPA suggests that rugs be reinforced for safety. Dining Area: The dining area consists of (6) six chairs and a large table. All furniture is in new condition. Thermostat was being worked on by apartment complex maintenance at the time of the inspection and in the presence of the LPA. Thermostat was fixed and set at 70 degrees. Kitchen: The kitchen was observed to be clean and organized. The kitchen stove is gas operated with 5 burners, sink, refrigerator with freezer, dishwasher and telephone. Disinfectants are located under the kitchen sink,with lock box for sharp knives which are locked and inaccessible Licensee uses a child-proof sliding combination lock to lock these items in cabinets. There is enough perishable food and non-perishables. (S1) will purchase additional snacks. Water is purchased in bulk. There is a fire extinguisher with recent inspection. CONTINUES ON LIC-809C PAGE 1 of Hallway Closet: contains emergency ladder and cleaning equipment. Hallway: has framed posted Foster Child Personal Rights, LIC610C, Emergency numbers and facility sketch Bedroom #1: is equipped with (1) one twin size bed, linen, blankets, pillows, adequate lighting, and closet space. There is (1) one night stand and (1) one dresser. Windows have screens and are operable. Additional linens are stored in the closet. Bedroom #2: is equipped with (2) two twin size beds, linen, blankets, pillows, and adequate lighting. There are (2) two night stands and (2) two dressers, and a closet. Additional linens are stored in the closet. Client Bahroom #1: is a full bathroom. Toilet, (1) sink and shower are in good condition. Laundry Closet/Medication Room: This is a side by side laundry unit washer and dryer. There are additional hygiene products such as soap, toothpaste, toothbrushes, hair products, deodorant, towels, laundry detergents, and medication logs locked in cabinets. Personal hygiene products will be stored in caddys also stored in the closet. Medication Administration (MAR) Binder and PRN is also locked in cabinets. First Aid Kit was observed to be equipped with the required items inside (age-appropriate, scissors, tweezers, thermometer, and gauzes, antiseptic). Master Bedroom /Office#1: will be utilized and accessible to staff only. Bathroom #2 is a full bathroom located in this room. Toilet, (1) sink and shower are in good condition. Sliding door leads to a small balcony and has a locking mechanism. Vehicle:There is a vehicle which will be used to transport clients. Vehicle is a Porsche Cayenne in good condition with current registration and insurance with Liberty Mutual Insurance Company . There is a Maxi-Cosi All-In-One child car seat in good condition. Per (S1) Criminal Record Clearance states "in process" on Guardian. LPA suggested that livescan pending elligible to work may take some time and a Component 3 meeting will be held once staff obtain eligible clearance. An exit interview was conducted. A copy of this report left with prospective licensee. (S1) whose signature on this form confirm receipt of these documents.

met_with: Ivery Harris Prospective Licensee and Sherri Parker


state: CA

summary: Facility Evaluation

raw_content:
Narrative:
On 07/05/24 at 1:35pm, Licensing Program Analyst (LPA) Christine Wilson conducted a Component 2 meeting via Teams with Applicant Ivery Harris and Sherri Parker. The purpose of the meeting was to discuss the application review, utilizing the Section A and B components. and any required verifications, or research of discrepancies or concerns involving the application and additional drafts. The following was discussed with the applicant: 1. Formatting of the Program Statement to include page numbers and a table of contents. 2. General Regulations 80075(B)(2) - Applicant Ivery Harris and Sherri Parker to provide copy of nursing license and/or training certification to administer injections to clients. 3. Chapter 4 Activities - Applicants stated that they would like to understand regulations regarding taking clients away from home and on vacations. LPA Wilson explained reasonable prudent parent standard, and advised applicants to adhere to both licensing standards, as well as any standards from placement agencies. 4. Activities - Applicant is to amend the program statement, to include how vacation activities will be addressed, including references to all standards of care, medical services, behavior tokens, meals, transportation, emergencies, needs and services, and reporting requirements. 5. LPA advised applicant to inform the Department/assigned LPA, whenever they leave the home for any extended time. Any persons in positions of care and supervision of children should obtain a cleared criminal record. 6. LPA advised applicants have 30 days from today's date, to submit the 3rd draft of the program statement LPA Wilson stated the New Component Orientation will not be ready by the State until August, yet applicant may be required to attend, and that if so, LPA will register the applicant for it. LPA will follow up with LPM Kevin Sauk to discuss. End of meeting 2:15pm

report_type: Facility Evaluation

met_with: Ivery Harris and Sherri Parker.


summary: Facility Evaluation

raw_content:
Narrative:
On December 20, 2024, at 09: AM, Licensing Program Analyst (LPA) Miguel Gomez, Licensing Program Analyst (LPA) Emelyn Sanchez Peralta and Licensing Program Manager (LPM) Lakescia Smith made an unannounced visit to Our Haven House Small Family Home for the purpose of conducting post licensing inspection. LPA Gomez, LPA Sanchez Peralta and LPM Smith met with Assistant Caregiver, Sherri Parker, who granted access into the home. The facility is licensed to provide care and supervision for ambulatory developmentally disabled children ages 3-17. The census on the date of this visit is one The home is set-up as follows: This is a unit located on the second floor, located in an apartment community. Apartment contains garage, living room, dining area, kitchen, two bedrooms, hallway closet, client bathroom, laundry/medication room, and office with bathroom. Garage: This area is equipped for two (2) vehicles. Living Room: The living room is fully furnished. The living room is a common area with seating for five (5), television and two area rugs. All furniture is in new condition. Dining Area: The dining area consists of (6) six chairs and a large table. All furniture is in new condition. Kitchen: The kitchen was observed to be clean and organized. The kitchen stove is gas operated with 5 burners, sink, refrigerator with freezer, dishwasher, and telephone. Disinfectants are located under the kitchen sink, with lock box for sharp knives which are locked, and inaccessible. Licensee uses a child-proof sliding combination lock to lock these items in cabinets. There is enough perishable food and non-perishables. Fire extinguisher is fully charged. Hallway Closet: contains emergency ladder and cleaning equipment. Hallway: has framed posted Foster Child Personal Rights, Emergency Disaster Plan (LIC 610C), Emergency contact numbers and facility sketch. Bedroom #1: is equipped with (1) one twin size bed, linen, blankets, pillows, adequate lighting, and closet space. There is (1) one night stand and (1) one dresser. Additional linens are stored in the closet. Bedroom #2: is equipped with (2) two twin size beds, linen, blankets, pillows, and adequate lighting. There are (2) two night stands and (2) two dressers, and a closet. Windows have screens and are operable. Client Bathroom #1: is a full bathroom. Toilet, (1) sink and shower are in good condition.Master Bedroom: Licensee's room with Bathroom #2 is a full bathroom located in this room. Toilet, (1) sink and shower are in good condition. Sliding door leads to a small balcony and has a locking mechanism. Laundry Closet/Medication Room: This is a side-by-side laundry unit washer and dryer. There are additional hygiene products such as soap, toothpaste, toothbrushes, hair products, deodorant, towels, laundry detergents, and medication logs locked in cabinets. Medication Administration Record (MAR) and PRN logs is also locked in cabinets. First Aid Kit was observed and included age-appropriate, scissors, tweezers, thermometer, and gauzes, antiseptic. Vehicle: There is a vehicle which will be used to transport clients. Vehicle is a Porsche Cayenne in good condition with current registration and insurance with Liberty Mutual Insurance Company. Children in care will be supervised and protected at all times. Children will be accorded dignity in personal relationships with staff and others. Children can contact the licensing agency or Foster Care Ombudsperson in confidence without threats or punishment for making complaints. The home was inspected, and the following was observed: The home is clean, safe, and sanitary. The home will operate within the capacity and limitations of the license. Hot water kept at a safe temperature. The beds have comfortable mattresses, clean linens, blankets, and pillows, all in good repair. Caregiver maintains a safe and comfortable temperature in the home. All smoke detectors and carbon monoxide detectors tested audible and were working properly. No guns or weapons are in the home. There is a working telephone accessible for use at all times. Outdoor activity space is free of obstruction and debris. Based on the observations made during today's inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit Interview was conducted, and a copy of this report will be provided to Sherri Parker.

met_with: Sherri Parker


summary: Facility Evaluation

raw_content:
Narrative:
On August 7, 2027, at 09: AM, Licensing Program Analyst (LPA) Miguel Gomez made an unannounced visit to Our Haven House Small Family Home for the purpose of conducting annual inspection. LPA Gomez met with Assistant Caregiver, Sherri Parker, who granted access into the home. The facility is licensed to provide care and supervision for ambulatory developmentally disabled children ages 3-17. The census on the date of this visit is one The home is set-up as follows: This is a unit located on the second floor, located in an apartment community. Apartment contains garage, living room, dining area, kitchen, two bedrooms, hallway closet, client bathroom, laundry room, and office/medication room with bathroom. Garage: This area is equipped for two (2) vehicles. Living Room: The living room is fully furnished. The living room is a common area with seating for five (5), television and two area rugs. All furniture is in good condition. Dining Area: The dining area consists of (6) six chairs and a large table. All furniture is in goo condition. Kitchen: The kitchen was observed to be clean and organized. The kitchen stove is gas operated with 4 burners, sink, refrigerator with freezer, dishwasher, and telephone. Disinfectants are located under the kitchen sink, with lock box for sharp knives which are locked, and inaccessible. Licensee uses a child-proof sliding combination lock to lock these items in cabinets. There is enough perishable food and non-perishables. Fire extinguisher is fully charged. Hallway Closet: contains emergency ladder and cleaning equipment. Hallway: has framed posted Foster Child Personal Rights, Emergency Disaster Plan (LIC 610C), Emergency contact numbers and facility sketch. Bedroom #1: is equipped with (1) one twin size bed, linen, blankets, pillows, adequate lighting, and closet space. There is (1) one night stand and (1) one dresser. Additional linens are stored in the closet. Bedroom #2: is equipped with (2) two twin size beds, linen, blankets, pillows, and adequate lighting. There are (2) two night stands and (2) two dressers, and a closet. Windows have screens and are operable. Client Bathroom #1: is a full bathroom. Toilet, (1) sink and shower are in good condition.Master Bedroom/Medication Room: This: Licensee's room with Bathroom #2 is a full bathroom located in this room. Toilet, (1) sink and shower are in good condition. Sliding door leads to a small balcony and has a locking mechanism. Medication Administration Record (MAR) and PRN logs is also locked in cabinets. First Aid Kit was observed and included age-appropriate, scissors, tweezers, thermometer, and gauzes, antiseptic. Vehicle: There is a vehicle which will be used to transport clients.Vehicle-I Porsche Cayenne is in good condition with current registration and insurance with Liberty Mutual Insurance Company. Laundry Room is a side-by-side laundry unit washer and dryer. There are additional hygiene products such as soap, toothpaste, toothbrushes, hair products, deodorant, towels and laundry detergents. Children in care will be supervised and protected at all times. Children will be accorded dignity in personal relationships with staff and others. Children can contact the licensing agency or Foster Care Ombudsperson in confidence without threats or punishment for making complaints. The home was inspected, and the following was observed: The home is clean, safe, and sanitary. The home will operate within the capacity and limitations of the license. Hot water kept at a safe temperature. The beds have comfortable mattresses, clean linens, blankets, and pillows, all in good repair. Licensee maintains a safe and comfortable temperature in the home. All smoke detectors and carbon monoxide detectors tested audible and were working properly. No guns or weapons are in the home. There is a working telephone accessible for use at all times. Outdoor activity space is free of obstruction and debris. Based on the observations made during today's inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit Interview was conducted, and a copy of this report will be provided to Sherri Parker.

visit_type: Annual

met_with: Sheri Parker


facility_name: OWENS SMALL FAMILY HOME

summary: Facility Evaluation

raw_content:
Narrative:
On November 23, 2021 at 9: AM, Licensing Program Analyst (LPA) Charmetha White made an unannounced inspection visit to Owens Small Family Home for the purpose of conducting an Annual Random Inspection. LPA met with the Licensee, who granted access to the home and together a tour of the entire home was conducted. The facility is licensed to provide care and supervision services for four (4) female developmentally disabled and/or medically fragile children, ages 3-17 years old, ambulatory only. The census today is zero (0) and living in the home currently are the Licensee and the Licensee's Mother. The program accepts Regional Center Placement Children. The facility is set up as follows: This is a two--story 6 bedrooms 2 ½ bathroom, home located in a residential area. The home has a living room, dining room, kitchen, a pantry area, a laundry area, and a backyard. Living Room: is equipped with a two sofas, a screened fireplace, a small glass table, and a cabinet. Dining Room: is equipped with a wooden table and six (6) chairs. Kitchen: is equipped with a four (4) burner stove, a wall oven, a refrigerator/freezer, a microwave, and a dishwasher. There is also a sliding glass patio door which opens to the backyard. Sharp knives are kept in a locked kitchen drawer and made inaccessible to children in care. The food service is adequate with perishable and nonperishable food supplies. Pantry area: is located between the dining room and kitchen and contains additional food supplies. Laundry area: is located off the kitchen and it is equipped with a washer and dryer. Backyard: is free from obstructions and contains a small shed which LPA observed is used for storage. Bedroom #1: Is located downstairs and is vacant. The room is equipped two twin size beds. The room has a closet and drawer space, working lights, and windows. Bedroom #2: Is located downstairs and is occupied by Licensee. The room is equipped two twin size beds. The room has closet and drawer space, working lights, and a window. Bedroom #3: Is located downstairs and is used as an office space with a desk, chair, and a filing cabinet. Bedroom #4: Is located upstairs and is vacant. The room is equipped a queen size bed. There are adequate drawers, closet space, working lights, and a window. Report continued on LIC 809-C Bedroom #5: Is located upstairs and is vacant. The room is used for storage. Bedroom #6: Is located upstairs and is occupied by Licensee's Mother. The room is equipped a queen size bed. There are adequate drawers, closet space, a working light, and windows. LPA observed the home to be clean, safe, sanitary and in good repair. The home has a working telephone readily accessible to children in care. There are no security bars on the windows of the home. Disinfectants and Cleaning solutions are made inaccessible to the children. Caregiver maintains a safe and comfortable temperature in the home. Hot water is kept at a safe temperature. LPA observed the home to have ( ) fully charged fire extinguisher. The smoke and carbon monoxide detectors were tested and found to be in working order. The First Aid Kit was checked and found to be complete. LPA observed passageways, stairways, inclines, ramps and open porches were unobstructed. The front and backyard were clean and free of debris. There are no firearms or dangerous weapons in the home. There was no swimming pool, hot tub, spas, nor similar bodies of water located at the facility. Adequate supervision will be provided for children when in care. Caregiver will provide and ensure three nutritious meals, snacks and special diets. LPA reminded Licensee to ensure the following when children are in placement: Children are accorded personal rights and the corresponding form is in their file. Children are supported and encouraged to participate in extracurricular activities. Children are allowed and encouraged to contact the licensing agency, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. Licensee acknowledges abuse reporting requirements. Licensee's First aid/ CPR training is valid until 01/27/2023. Emergency telephone numbers are posted in a prominent location. Caregiver has not conducted any training hours. Licensee and adults residing in the home have DOJ/FBI criminal record clearances as well as Child Abuse Index Checks. During the visit, 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 Small Family Home Licensure and Emergency Plan were met. The home currently has no staff or clients placed in the home. Licensee was issued an advisory note regarding ongoing training hours. PER California Code Regulation, TITLE 22, DIVISION 6, CHAPTER 4 no deficiencies were cited during this visit.

met_with: Licensee - Carol Owens


facility_name: PAMA SMALL FAMILY HOME

summary: Complaint Investigation - Unsubstantiated - 1 allegation

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

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

report_type: Complaint Investigation

met_with: Naneth Caderao - Licensee

complaint_status: unsubstantiated


summary: Facility Evaluation

raw_content:
Narrative:
On Thursday 7/29/21 at 1:05PM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility for a required annual inspection. LPA met with Licensee Naneth Pama Caderao and informed of the purpose of the visit. Safety precautions were taken, including a pre-visit screening call, at-visit temperature screening, hand hygiene, and mask-wearing. The facility has three staff and three children in care. LPA conducted confidential interviews with staff and residents. Interviews did not indicate any violations. LPA utilized the Inspection Tool to conduct the inspection. LPA observed the facility files to meet the requirements with the following exceptions: There is no LIC Register of Clients or equivalent. LPA advises, per Title 22, Section 80071, that Licensee acquire the form, fill out, and keep it in a central location in the home. LPA provided a copy of the form to Licensee. Residents R1 and R2 (See LIC Confidential Names) did not have medical assessments in their files. Per Licensee, the doctor for one youth and the mother for the other youth need to send them over to Licensee. LPA advises, per Title 22, Section 80070, that Licensee ensure that the medical and capabilities assessment is obtained within 30 days of placement. The psychotropic medications were not logged on separate logs. The medication administration records were otherwise very well organized with no inconsistencies. LPA advises, per Title 22, Section 83070, that Licensee begin using the "PMAR," which LPA provided to Licensee, for all psychotropic medications. All three staff have a health screening form signed by the staff member but not filled out or signed by a physician. LPA advises, per Titel 22, Section 80066, that Licensee ensure all staff have a health screening, clearance for work, and a negative TB test result on file. LPA inspected the facility site and observed the facility to be clean, sanitary, and in good condition. The grounds were free of obstruction and mess. There were no hazards or bodies of water. Per Licensee, there are no firearms or ammunition on the premises. Room and hot water temperatures measured within permitted ranges. A can of disinfectant spray was observed on a high shelf in an unlocked closet from when. Licensee used it earlier today, but Licensee immediately moved it to the locked chemicals storage. There are no citations. Four advisories were provided at today's visit. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Licensee Naneth Pama Caderao, whose signature on this form confirms receipt.

met_with: Licensee Naneth Pama


summary: Facility Evaluation

raw_content:
Narrative:
On Monday 7/11/22 at 10:30AM, Licensing Program Analyst (LPA) Lisette Valenzuela made an unannounced visit to the above facility for a required annual inspection. LPA Valenzuela met with Licensee Naneth Caderao and informed of the purpose of the visit. LPA Valenzuela inspected the facility site and observed the facility to be clean, sanitary, and in good condition. The grounds were free of obstruction and mess. There were no hazards or bodies of water. LPA Valenzuela observed, the license, Emergency Disaster Plan, Personnel Report, and appropriate posters were posted in an accessible location. Per Licensee, there are no firearms or ammunition on the premises. LPA Valenzuela checked both the room temperature and the water temperature and observed it was kept at a comfortable temperature within the permitted range. The kitchen was stocked the adequate essentials to meet the client needs. Sharps and knives were stored in a locked drawer in the staff room, and chemicals were stored in locked cabinets in the locked laundry room. Food storage was sanitary and organized, and the pantry was stocked with food to meet the 7-day nonperishable, 2-day perishable mandate. Medications were locked away and separated by resident. Bedrooms were clean,linens were clean, and each resident has their own bed and closet/drawer space. The facility has four staff members and two clients currently in care. LPA Valenzuela conducted a confidential interview with the Licensee Naneth Caderao. The interview conducted did not indicate any violations. During visit, LPA Valenzuela observed that staff interact with the residents and maintain appropriate staff-client ratios. LPA Valenzuela reviewed 2 client files and 4 staff files. All files were complete and contained all the correct documentation for both client and staff files. At this time, per Title Regulations, no deficiencies were cited during this inspection. An exit interview was conducted, and a copy of this report will be emailed to Licensee Naneth Pama Caderao, whose signature on this form confirms receipt.

met_with: Licensee Naneth Caderao


summary: Facility Evaluation

raw_content:
Narrative:
On Wednesday 8/31/22 at 2:15PM, Licensing Program Analyst (LPA) Lisette Valenzuela made an unannounced visit to the above facility for a Case Management - Annual Continuation inspection. LPA Valenzuela met with Caregiver Janna Po and informed her of the purpose of the visit. Caregiver Janna Po assisted LPA Valenzuela with a walkthrough of the facility. LPA Valenzuela observed the facility to be clean, grounds were free of obstruction, and there were no hazards or bodies of water. LPA Valenzuela observed, the License, Emergency Disaster Plan, Personnel Report, and appropriate posters were posted inside of the facility. LPA Valenzuela checked both the room temperature and the water temperature and observed it was kept within the permitted range. The kitchen was stocked the adequate essentials to meet the client needs. Sharps and knives were stored in a locked drawer in the staff room, and chemicals were stored in locked cabinets in the locked laundry room. Medications were locked away. LPA Valenzuela observed the bedrooms to be clean, and each client has their own bed and closet space. During the time of visit, there was 1 client out of 2 present. The second client was at school and is non-verbal. LPA Valenzuela observed the client and staff interacting. The client was being treated with respect and kindness, and no safety concerns were observed. LPA Valenzuela asked if the client that was present could be interviewed and caregiver approved. LPA Valenzuela was able to conduct a confidential interview with 1 client. LPA Valenzuela conducted a confidential interview with 1 staff member. (Please see LIC 812 for interviews.) At this time, per Title Regulations, no deficiencies were cited during this inspection. An exit interview was conducted, and a copy of this report will be emailed to Caregiver Janna Po whose signature on this form confirms receipt.

visit_type: Case Management

met_with: Janna Po


summary: Facility Evaluation

raw_content:
Narrative:
On 8/30/23, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the home for a required annual inspection. LPA met with Licensee Naneth Pama and informed of the purpose of the visit. The CARE Inspection Tool was used to complete this inspection. LPA toured the facility site and inspected facility records. LPA observed the facility to be clean and organized and maintained in safe condition. No hazards were observed. Medications and chemicals are locked away and stored separately and safely. The ktichen is fully stocked with quality food. One assistant caregiver (S1 - See LIC Confidential Names) did not have a current and valid association to the facility. LPA is issuing a citation of California Code of Regulations, Title 22, Section Criminal Record Clearance. See LIC 809-D attached. Additionally, pursuant to Section 80019, LPA is assessing a civil penalty for the criminal record clearance violation, totaling $500. See LIC 421BG. No other deficiencies were observed. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Licensee Naneth Pama, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 08/14/2024 at 12:30 p.m., Licensing Program Analyst (LPA) Brenda Rodriguez conducted an unannounced Annual Inspection and met with Janna Po, Lead Staff. LPA Rodriguez disclosed the purpose of the inspection and was granted entry into the facility. LPA Rodriguez used the CARE Inspection Tool. The facility currently has a census of four (4) minor clients. No more than two clients share a bedroom. During the physical plant inspection, no deficiencies were found. The facility and grounds are clean, tidy, and free of obstructions. There are no hazards on the premises and no firearms, per Administrator. Bedrooms are double-occupancy, and beds have clean linens and mattress pads. There is enough storage for residents' personal belongings. Food is of good quality, within date, and stored properly. Room temperature was 70 degrees maintained at a comfortable temperature within permitted range. LPA Rodriguez reviewed four (4) staff files and four (4) client files. The documentation in the clients file is complete. LPA Rodriguez reviewed staff training that is done, certificates, and everything is up to date. LPA Rodriguez conducted two confidential staff interviews and two confidential client interviews. The required annual inspection is complete. No deficiencies were cited. An exit interview was conducted at 3:57 p.m., and a copy of this report was emailed to Administrator Naneth Caderao, whose signature on this form confirms receipt.

met_with: Janna Po, Lead Staff and Naneth Caderao, Adminstrator


summary: Facility Evaluation

raw_content:
Narrative:
On 07/30/2025 at 10:30 a.m., Licensing Program Analysts (LPAs) Omar Sawyer and LPA Jonathan Medina conducted an unannounced Annual Inspection and met with Licensee, Naneth Caderao. LPA Sawyer disclosed the purpose of the inspection and was granted entry into the facility. At the time of the visit there are Staff working and Clients at the facility. The CARE Inspection Tool was used during the visit. During the inspection, LPAs obtained an updated LIC 500 (Personnel Report) to ensure the facility's records are current. A review of the Guardian background check system on July 30, 2025, confirmed that all staff associated with the program had cleared Department of Justice (DOJ), Federal Bureau of Investigation (FBI), and Child Abuse Central Index (CACI) background checks. One staff member is currently listed as "in process." Upon interview with the Licensee LPA's were informed that potential Staff has not worked at the facility and will not be hired. The facility currently has a census of three (3) minor clients, with no more than two clients sharing a bedroom. At 10:45 a.m., LPAs reviewed four (4) staff files and three (3) client files. Client files were complete and contained admission agreements, consent forms, emergency contact information, personal property/valuables lists, and signed personal rights acknowledgments. Staff files contained required documentation, including current First Aid/CPR certifications, fingerprint clearances, educational verification, TB test results, criminal record statements, health screenings, personnel records, and employee rights forms. Staff training records and certificates were reviewed and found to be current. Continues on LIC809-C At 12:30 p.m., during the physical plant inspection, no deficiencies were observed. The facility and grounds were found to be clean, orderly, and free of obstructions or hazards. According to the Administrator, there are no firearms on the premises. Bedrooms are double-occupancy, and each bed is equipped with clean linens and mattress pads. Adequate storage is available for resident's personal belongings. Food was observed to be of good quality, within expiration dates, and properly stored. The water temperature measured 109°F, and the thermostat reading was 72°F, both within regulatory limits. Clients' medications were stored appropriately, Medication Administration Records (MAR) and Psychotropic Medication Administration Records (PMAR) accurately reflected administration. Staff had up-to-date First Aid and crisis intervention training. At 1: LPAs reviewed the operations section of the CARE tool. No deficiencies were observed in this section. Home is currently operated as stated on license and plan of operation. LPAs conducted one confidential staff interview and one confidential client interview. The required annual inspection is complete. No deficiencies were cited. An exit interview was conducted at 2:45 p.m., and a copy of this report was given to Administrator Naneth Caderao, whose signature on this form confirms receipt.

met_with: Naneth Caderao, Licensee/Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Control Number - 2466-FN On December 5, 2025 at 10: AM, Licensing Program Analysts (LPAs) Jonathan Medina and Amee Li conducted an unannounced case management inspection at the above-referenced facility to follow up on a submitted Incident Report (IR). LPAs met with the Licensee, Naneth Pama Caderao. At the time of the visit, two staff members and one client were present. Towards end of visit all other clients arrived from school. The IR under review was submitted regarding an incident that occurred on November 30, 2025. According to the report, two clients were allegedly involved in viewing inappropriate videos together. The father of C1 (client 1) entered the home without authorization to personally question C2 (client 2) and determine if the incident had occurred. C2 denied the allegations. Law enforcement responded and interviewed staff, but did not interview the clients. On todays visit LPAs conducted interviews with staff and client. After reviewing the regulations for a Small Family Home, the clients' Needs and Services Plans, the staff schedule, and conducting confidential interviews with staff and client, LPAs determined that the facility appropriately handled the situation. However, upon review of the incident, it was found that the facility did not have a bedroom-sharing agreement document in place. This is a violation of California Code of Regulations (CCR), Title 22, Section 83087(g) - Building and Grounds. Please refer to LIC 809-D for additional details. As a follow-up to the incident, the home will enforce parents calling prior to making a visit per the house rules. The father did not respect house rules and disregarded staff's attempts to prevent him from accessing C2's room. There was no indication of the alleged behaviors in C2's Individualized Program Plan (IPP). However, C1's IPP did document disrobing and sexually maladaptive behaviors. Due to this, there was a 1:1 staff at all times for C1. It was also revealed the laptop in C2's possession was a school issued Chromebook, which has content restrictions in place. An exit interview was conducted, and a copy of this report was provided to Licensee Naneth Pama Caderao, whose signature confirms receipt of the report.

met_with: Licensee - Naneth Pama Caderao


facility_name: PAW PAW'S HOUSE

summary: Facility Evaluation

raw_content:
Narrative:
On August 5th, Licensing Program Analyst (LPA) Cynthia Ramos and Licensing Program Manager Abdoulaye Traore (LPM) met with applicant Nijeia Laws this date for a Component II. LPA and LPM went over revisions needed for the application prior to licensure. LPA and LPM gave a copy of the LIC 184, Letter of Application Revision, and additional correspondence to assist with the revisions needed to the application. A copy of this report was provided to applicant Nijeia Laws.

met_with: Nijeia Laws


summary: Facility Evaluation

raw_content:
Narrative:
On September 25th, 2025, at 9:55AM Licensing Program Analyst (LPA) Cynthia Ramos completed a Pre-Licensing inspection at Paw Paw's Home Small Family Home (SFH). LPA met with Applicant Nijeia Laws who led a tour of the home. The facility was toured both inside and out with the Applicant. There are no children in placement. The home is a two-story town home, with four bedrooms and three full bathrooms which are set up as follows: On the first floor of the home there is Bedroom #1 which contained a queen size bed and was currently occupied by adult male. The kitchen, dining room and living room were also located downstairs. The kitchen was observed to be organized and clean and there was enough perishable and non-perishable food items. On the second floor, Bedroom #2 contained a queen size bed, this room sleeps female adult. Bedroom #3 consisted of 2 twin size beds with enough storage space and closet space, this room will be used for future children. Bedroom #4 is the master bedroom which consist of king size bed and sleeps the Applicant. Per Applicant, all adult bedrooms remain lock at all times. LPA observed all children's beds had linen, comforters, and pillows. All bathrooms in the home were inspected and were in good working conditions. The laundry room was located upstairs and contained chemicals/cleaners that were locked. There was also a loft area that was used for recreational area and office space. The garage and side patio were also inspected, and no hazards were observed. The children's bedrooms were arranged so that no more than two children will be in a room. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There was a smoke detector in every bedroom. The carbon monoxide/smoke alarms were tested and working properly. Continued on the Next Page... The home's central air conditioning module was inside the home behind the kitchen. The water heater was in the garage. The water temperature was measured at 133.3 degrees Fahrenheit. All appliances were in working order at the time of inspection. Per Applicant, medications were locked inside each adult's bedroom. Sharp items, chemicals and cleansers were locked under the kitchen sink. There was three fire extinguishers present in the home, one was located outside the home, living room and upstairs. Fire extinguishers were observed to be properly charged and inspected by the Fire Department. The First Aid Kit was located in the loft area will be accessible to future children in care. Per Applicant, there are no weapons in the home. There is no pool in the home, however there is a community pool that is not accessible to the children as it remains locked at all times and is fenced. The home has a total of 3 cameras, one is located outside the home, one in the living room and one upstairs in the loft area. Corrections: Trashcans with tight fitting lids Thermometer for First Aid Kit Tweezers for First Aid Kit Medication box with lock Water temperature needs to between 105-120 degrees F. Remove additional bed located in children's closet Component III was conducted at the time of Pre-Licensing Inspection. An exit interview was conducted, and a copy of this report was provided to Applicant Nijeia Laws and application will be forwarded to Licensing Program Manager Abdoulaye Traore once corrections are submitted to LPA.

visit_type: Prelicensing

met_with: Applicant- Nijeia Laws


summary: Facility Evaluation

raw_content:
Narrative:
On October 2, 2025, Licensing Program Analyst (LPA) Cynthia Ramos met with applicant Nijeia Laws to check the water temperature of her home from the pre-licensing inspection correction that was conducted on 9/25/25. Hot water temperature was at 130 degrees Fahrenheit. LPA advised Applicant for water to be corrected.


summary: Facility Evaluation

raw_content:
Narrative:
On April 23rd, Licensing Program Analyst (LPA) Cynthia Ramos arrived at Paw Paw's Home Small Family Home (SFH) for the purpose of conducting a Post-Licensing inspection. LPA met with Licensee Nijeia Laws who led a tour of the home. The facility was toured both inside and out with the Licensee. There was currently one client placed in the home. The home is a two-story town home, with four bedrooms and three full bathrooms which were set up as follows: On the first floor of the home there was Bedroom #1 which contained a queen size bed and was currently occupied by adult male. The kitchen, dining room and living room were also located downstairs. The kitchen was observed to be organized and clean and there were enough perishable and non-perishable food items. Per Licensee, sharps items and knives are locked inside the Bedroom #1. On the second floor, Bedroom #2 contained a queen size bed, this room sleeps female adult. Bedroom #3 consisted of 2 twin size beds with enough storage space and closet space, this room was currently occupied by 16-year-old male client. LPA observed client's beds had linen, comforters, and pillows. Bedroom #4 was the master bedroom which consisted of king size bed and sleeps the Licensee. Per Licensee, all adult bedrooms remain lock at all times. Chemicals/cleaners were located in the laundry room upstairs and remain locked at all times. There was also a loft area that was used for recreational area and office space. The garage and side patio were also inspected, and no hazards were observed at the time of inspection. All bathrooms in the home were inspected and were in good working conditions. ... The clients bedrooms were arranged so that no more than two clients will be in a room. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There was a smoke detector in every bedroom. The carbon monoxide/smoke alarms were tested and working properly at the time of inspection. The home's central air conditioning module was inside the home behind the kitchen. The water heater was in the garage. The water temperature was measured at 116.7 degrees Fahrenheit. All appliances were in working order at the time of inspection. There was three fire extinguishers present in the home, one was located outside the home, living room and upstairs area. Fire extinguishers were observed to be properly charged and inspected by the Fire Department. The First Aid Kit and medication box were located in a cabinet in the loft area. Per Licensee, there are no weapons in the home at this time. There is no pool in the home, however there is a community pool that is not accessible to the client's as it remains locked at all times and is fenced. The home has a total of 3 cameras, one is located outside the home, one in the living room and one upstairs in the loft area. A total of 3 staff files and 1 client file were reviewed and were in compliance. Based on today's inspection, there are no deficiencies being cited at this time. An exit interview was conducted, and a copy of this report was provided to Licensee Nijeia Laws.

met_with: Licensee, Nijeia Laws


facility_name: PEACE & LOVE SMALL FAMILY HOME

raw_content:
Narrative:
denied seeing any individuals smoke or vape at the facility. Regarding the allegation that S1 is never at the facility, confidential interview provided conflicting information. Some interviews indicated that S1 is not at the facility a few nights at a time, due to their employment. Other interviews indicated that S1 is at the facility every night. LPA was unable to interview all individuals, although multiple attempts were made, thus, confidential interviews could not confirm or deny the allegation. Accordingly, confidential interviews did not corroborate the allegation with a preponderance of evidence. Based on confidential interviews and records reviewed the allegation that licensee did not ensure adequate supervision was provided to minor in care, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report, LIC 811, and appeal rights were provided to Sylvia Lizarraga. A copy of this report will be placed in the facility file.

Investigation Findings:
13On May 19, 2025, at 1:50 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Sylvia Lizarraga, Caregiver, to discuss the investigative finding for the allegation noted above. LPA Adaleyci Caballero conducted an inspection of the facility on January 13, 2025, at 1:15 pm and no deficiencies were observed. LPA Rachel Vanegas interviewed two Clients (FC1-2) and two Staff (S1-2). LPA Linley interviewed one Client (C3), three Staff (S4-6), and LPA was unable to interview one Staff (S3), and three County Social Workers (CSW1-3), despite multiple attempts to contact them. LPA reviewed the facility documents during the investigation. On January 3, 2025, Community Care Licensing (CCL) received an allegation that the licensee did not ensure adequate supervision was provided to minor in care. It was reported that the staff smoke marijuana on a daily basis and S1 is never at the facility. Confidential interviews revealed conflicting statements. Some interviews indicated some of the clients have been observed at school with vape pens. Other interviews UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 61-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: PEACE & LOVE SMALL FAMILY HOMEFACILITY NUMBER: VISIT DATE: 05/19/2025

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

met_with: Sylvia Lizarraga


raw_content:
Narrative:
Confidential interviews provided information regarding the outing taking place in a separate and heavily secured venue. County social worker (CSW) informed LPA that CSW was not informed of the outing taking place prior to the clients and staff attending. SFH staff denied knowing of any inappropriate activities or substance use promotion at the event attended. Confidential interviews consistently stated that there was no offering of alcohol or cannabis to clients in care at the event attended. Confidential interviews consistently stated that staff and clients attended the concert to support local and live music performances. Based on confidential interviews the allegation that staff took a minor on an inappropriate outing may have occurred, however, it is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, a copy of this report, LIC 811, and appeal rights were reviewed and provided to Caregiver - Bertrand Moore Jr.

Investigation Findings:
13On September 17, 2025, at 01:41PM, Licensing Program Analyst (LPA) Rachel Vanegas met with Peace & Love Small Family Home (SFH) caregiver, Bertrand Moore Jr. to issue the finding for the above allegation involving clients (C1, C2, C3) listed on the confidential names list (LIC 811) dated 09/17/25. LPA spoke with the Licensee - Steven Johnson via phone who authorized Caregiver - Bertrand Moore Jr. to receive and sign this licensing report on the Licensee's behalf. On May 16, 2025 at 10:07AM, LPA Vanegas conducted a health and safety inspection of the SFH and no immediate health and safety hazards were observed. During the investigation LPA Vanegas reviewed three clients (C1, C2, C3) records. Additionally, LPA conducted interviews with three SFH staff, one county social worker, and two of three clients. One client declined to participate in an interview with LPA. On May 8, 2025, the Department received a complaint alleging that staff took minor on an inappropriate outing. It was specifically alleged that C1 was taken to a concert celebrating April 20 (4/20) at a cannabis themed concert. **Continued on the next page** UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Rachel Vanegas 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 61-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: PEACE & LOVE SMALL FAMILY HOMEFACILITY NUMBER: VISIT DATE: 09/17/2025

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

met_with: Bertrand Moore Jr. - Caregiver


summary: Facility Evaluation

raw_content:
Narrative:
On March 1, Licensing Program Analyst (LPA) Linda Haynes met with Applicant Steven Johnson via Microsoft Teams to complete a component II interview. A signed copy of this report will be placed in facility file.

met_with: Steven Johnson


summary: Facility Evaluation

raw_content:
Narrative:
On April 10, 2024 at 1: PM, Licensing Program Analyst (LPA) Linda Haynes completed a pre-licensing inspection of Peace & Love Small Family Home. LPA met with Applicant Steven Johnson who led a tour of the home. The facility was toured both inside and out with the applicant. Currently there are no clients in placement at this time. The home is a two story building with four bedrooms and three and one half bathrooms which are set up as follows: · Bedroom #1 (Applicants) has one bed will sleep the applicant. · Bedroom #2 (Client's) has two bed's, it will sleep two client's. · Bedroom #3 (Client's) has two bed's, it will sleep two client's. · Bedroom #4 (Client's) has two bed's, it will sleep two client's. · A great room/living room, kitchen, dining area, two bathrooms, laundry room, a two car garage, a loft, an office and the backyard. The Client's bedrooms were arranged so that no more than two client's will be in a room. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There was adequate closet space for the client's belongings. There was a smoke detector / carbon monoxide detector in every bedroom. The eight smoke detectors / carbon monoxide were checked, and they were working properly. The house is equipped with a fire sprinkler system. The home's central air conditioning module was located on the side of the house. The home's tank less hot water heater was located the garage. The appliances were in working order. The client's files will be locked inside a file cabinet in the master bedroom. There was adequate food storage space and a supply of two days of perishable foods and a week of non-perishable foods. A trash can for storage of solid waste had a tight-fitting lid and was present. The sharp knives will be in a locked cabinet above the stove. The medications will be located in a locked cabinet in the kitchen. The hot water in the master bath measured to be 107.8 degrees Fahrenheit, the hot water in bathroom two measured to be 110.4 degrees Fahrenheit, in bathroom three 114.8 degrees Fahrenheit and in bathroom four 117.1 degrees Fahrenheit. The home's First Aid kit was accessible and is located in the kitchen. The first aid kit is missing a thermometer, scissors, and first aid manual. There are three fire extinguisher's present in the home one is located in the kitchen by the kitchen cabinets, one is in the upstairs laundry rooms, and one in the upstairs loft area. They were observed to be properly charged and inspected by the fire department. Licensee stated there were no weapons/firearms in the home. There is no pool or other body of water at the home. The backyard where clients will have access to play is fenced. There is no land line phone in the home. The following corrections need to be made · Complaint hotline number needs to be posted · The following supplies are needed for the first aid kit o Thermometer o Scissors o First aid manual · Home phone line A Component III was completed. An exit interview was conducted. Application will be forwarded to the Licensing Program Manager for Licensing.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On May 6, 2025 at 10: AM, Licensing Program Analyst (LPA) Rachel Vanegas, arrived unannounced at Peace and Love Small Family Home (SFH) for the purpose of conducting a post licensing/annual inspection. LPA received verbal permission from the Licensee Steven Johnson via phone to meet with the Caregiver, Sylvia Lizarraga. Caregiver, Sylvia Lizarraga led a tour of the SFH both inside and outside. The SFH is a two story home with the following layout (four bedrooms and three and one half bathrooms): First floor contains: Bedroom #1 (Client) has two single beds. It sleeps one client and one bed is vacant. A staff lounge/office area, the kitchen - which contains the SFH's first aid kit with all required items, one living room utilized as a recreation space for clients in care and contains age-appropriate board games, etc., an access door to the attached garage that remains locked and inaccessible to children in care, a locked storage closet, one bathroom, and one half restroom, a locked filing cabinet where staff and client files are stored. Second floor contains: Bedroom #2 (Client) has two bed's. It sleeps one client and one bed is vacant. Bedroom #3 (Client) has two bed's, It sleeps one client and one bed is vacant. Bedroom #4 (Licensee's) has one bed and sleeps the Licensee. Client medications and sharp knives are locked in the Licensee's bedroom and inaccessible to client's in care. A loft, a locked laundry room, and two bathrooms. All bedrooms have adequate storage space for personal belongings in drawers and closets. All bedrooms are arranged so that no more than two clients are in one room and there is one client per bed. **.** LPA observed an adequate supply of perishable and non-perishable foods and posted meal menus in the kitchen. There was a trash can for storage of solid waste with a tight-fitting lid located in the kitchen. LPA observed required postings in the kitchen including the facility license, foster youth personal rights, Complaint Hotline, etc. Cleaning chemicals are located in a locked storage closet on the first floor and are inaccessible to client's in care. There are combination smoke detector/carbon monoxide detectors in every bedroom and hallway. The smoke detector/carbon monoxide detectors were tested and are in properly functioning order. There are two fire extinguishers in the home that are observed to be properly charged. One is located in the kitchen on the first floor and one is located outside of the laundry room on the second floor. The home has a tank less water heater located inside the garage and the temperature is set to 106 degrees Fahrenheit. The hot water temperature was checked in the kitchen and registered at 106 degrees Fahrenheit. The facility outside grounds were also inspected and were observed to be clean and well maintained. Emergency exits were free from obstruction. There is no pool or other body of water at the facility. LPA conducted three client file reviews for Client 1 (C1), Client 2 (C2), Client 3 (C3) and observed necessary documents in the files including, consent to medical treatment authorization forms, placement agreements, signed personal rights form, etc. Three out of three files (C1, C2, C3) did not contain documented results of tuberculosis (TB) screening or Needs and Services Plan's signed by authorized representatives. LPA conducted six staff file reviews for Staff 1 (S1), Staff 2 (S2), Staff 3 (S3), Staff 4 (S4), Staff 5 (S5), and Staff 6 (S6). LPA observed that two out of six staff files were not available or present at the SFH. LPA was unable to review staff files for S5 and S6 at the time of this inspection. S1, S2, S3, and S4 files contained necessary documents including CPR/First Aid certificates, Drivers License, Job Duties, Health Screening, etc. LPA observed that four out of four staff files present and reviewed did not contain signed acknowledgements for child abuse and neglect reporting requirements. The facility is issued one technical violation in accordance with California Code of Regulations (CCR) Title Section 80023(d)(2) for not having documentation of biannual disaster drills for proper Operations compliance with Disaster and Mass Casualty Planning. **** Also, one technical violation is issued in accordance with Child Abuse and Neglect Reporting Act Section 11165.7(c)(1) for not having signed acknowledgement for child abuse and neglect reporting requirements for S1, S2, S3, and S4 files. Based on observation and record review, the facility is being cited two Type B violations for client records in accordance with CCR Section 83068.2(b)(12) for C1, C2, and C Needs and Services plan not having authorized representative signatures and CCR Section 80069(c)(1) for not having documentation of a medical/tuberculosis (TB) examination on file for C1, C2, and C3 within 30 days of admission. Based on observation and record review, the facility is being cited two Type B violations for staffing records in accordance with CCR Section 80066(a) for the Licensee not maintaining staff files for S5 and S6, and CCR Section 83075(f)(2) for S5 and S6 not having documentation of First Aid and Cardio Pulmonary Resuscitation (CPR) on file. An exit interview was conducted and a copy of this report, LIC 811, and appeal rights were reviewed and provided to Caregiver, Sylvia Lizarraga.

Deficiencies:
80066(a): Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information

met_with: Sylvia Lizarraga - Caregiver


summary: Facility Evaluation

raw_content:
Narrative:
On October 13, 2025, an informal conference was held with Peace and Love Small Family Home (SFH) at the Riverside Children's Residential Program Office to discuss current Community Care Licensing (CCL) concerns. Present at the meeting were Jennifer Smith, Licensing Program Manager, Licensing Program Analysts (LPAs) Rachel Vanegas and Carissa Aviles, and Peace and Love SFH Licensee Steven Johnson. The following concerns were addressed: - Accountability - Care and Supervision - Misrepresentation of information provided to Community Care Licensing Licensing Program Manager (LPM) Smith discussed accountability, care and supervision, and the importance of providing the Department with accurate information that is true and correct at all times, and Licensee was reminded that the client's needs must be met and operational needs of the facility must be addressed on a continuous basis. LPM Smith advised that the Licensee must be active and functioning in his role in order to ensure accountability for the general supervision of the licensed facility and ensure established policies concerning its operational needs are implemented daily. LPM Smith requested clarity regarding who the primary caregiver of the Peace and Love SFH is. Licensee Johnson stated that he is the primary caregiver and resides in the home seven day a week. LPM Smith further requested clarity on Licensee Johnson's presence in the home during the time that children are present at the home. Licensee Johnson stated that he was regularly present in the home and will complete a declaration. Continued on the next page LPM Smith inquired about the daily schedule for the children in care to identify if the children are out of the home for school or other day programs. Licensee Johnson confirmed that one child is part of independent home studies and that two other children have on-going truancy concerns. LPM Smith advised Licensee Johnson that when children are in the home full-time, he needs to be regularly present. LPM Smith discussed and reviewed documents that were submitted to the Department by Licensee Johnson on the following dates: On June 13, 2025, LPA Vanegas received an emailed Plan of Correction (for post-licensing/annual inspection conducted on 05/06/25) from the Licensee dated 06/11/25 stating that S5, S6 and S7 were no longer employed at the SFH effective, 05/19/25. LPA Vanegas received a second email from the Licensee which included an updated LIC Personnel Report which removed S5 and S6, and did not include S7. LPM Smith discussed and requested clarification regarding two reference letters submitted for S7 by Licensee Johnson to the Department on 07/23/25 and a revised letter on 08/14/25. Licensee Johnson stated that S7 is his cousin and he worked with S7 many years at a different licensed facility prior to Peace and Love SFH. Licensee Johnson stated that dates provided for S7's employment on the reference letters were wrong and is not sure of the exact dates that S7 worked with him at Peace and Love SFH. Licensee Johnson stated that he does not have documentation or record of employment dates and further stated that he paid S7 in cash. Licensee Johnson confirmed that he did not write the reference letters but reviewed and authorized his signature on them for submission to the Department. LPM Smith also requested clarification regarding information provided on September 4, 2025 that S7 has not been scheduled to work due to personal leave of absence that began in October 2024 but remains cleared and eligible for employment. Licensee Johnson stated that he was uncertain of and could not verify exact dates of employment or leave of absence for S7. LPM Smith asked Licensee Johnson how he will verify that the information submitted to the Department is accurate, true, and correct. Licensee Johnson stated that he will verify all correspondence that is sent to the Department by reviewing it himself. Licensee Johnson stated that he understands that as the Licensee he is ultimately accountable. Continued on the next page LPM Smith discussed the importance of maintaining and monitoring eligible clearance for all staff. LPA Vanegas confirmed that Licensee Johnson has access to Guardian and reviewed current "In Process" staff. LPM Smith requested the following be submitted to Riverside North Regional Office (RNRO) by close of business on 10/27/2025: A plan of action detailing how the Licensee is actively functioning in the Licensee's role to ensure accountability for operational needs (including maintaining staff records) of the SFH. Updated LIC Personnel Report. A signed declaration that Licensee is residing in the facility seven days a week. An exit interview was conducted and a copy of this report, LIC 811, and appeal rights were reviewed and provided to Licensee Steven Johnson.

met_with: Licensee - Steven Johnson


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On September 17, 2025, at 12:15PM, Licensing Program Analyst (LPA) Rachel Vanegas, arrived unannounced at Peace and Love Small Family Home (SFH) for the purpose of conducting a case management visit. LPA spoke with the Licensee - Steven Johnson via phone who authorized Caregiver - Bertrand Moore Jr. to receive and sign this licensing report on the Licensee's behalf. LPA spoke to the Licensee regarding the staff file for Staff 6 (S6) not being available for review at the facility. Licensee stated that the only information he had for S6 was a health screening and background clearance from a previous employment at another facility. Licensee stated that the Licensee would gather and obtain the rest of the staffing documents for the staff file. Licensee clarified that S6's date of hire was 05/16/2024. LPA conducted five staff file reviews for Staff (S) S1, S2, S3, S4, and S5. Based on LPA interviews, observations, and records review the facility is being cited one Type B violation in accordance with California Code of Regulations (Title 22, Division 6) (CCR) Personnel Records Section 80066 (e) for not maintaining all personnel records at the facility site and available to the licensing agency for review. LPA Vanegas discussed the Plan of Correction with the Licensee via phone. An exit interview was conducted, a copy of this report, LIC 809D, LIC 811, and appeal rights were reviewed and provided to Caregiver - Bertrand Moore Jr.

Deficiencies:
80066(e): All personnel records shall be maintained at the facility site and shall be available to the licensing agency for review.

title:
1
2
3
4
5
6
780066(e) Personnel Records


summary: Facility Evaluation

raw_content:
Narrative:
On October 3, 2025, at 10:00AM, Licensing Program Analyst (LPA) Rachel Vanegas, arrived unannounced at Peace and Love Small Family Home (SFH). LPA spoke with the Licensee - Steven Johnson via phone who authorized Caregiver - Bertrand Moore Jr. to receive and sign this licensing report on the Licensee's behalf. The purpose of this visit was to follow up regarding information obtained during an investigation involving an incident that occurred on or around May 8, 2025. Based on LPA interviews, observations, and records review the facility is being cited one Type B violation in accordance with California Code of Regulations (Title 22, Division 6) (CCR) Reporting Requirements Section 80061(b)(1)(E) for not reporting an unusual incident which threatens the physical or emotional health or safety of any client. An exit interview was conducted and a copy of this report, LIC 811, and appeal rights were reviewed and provided to Caregiver, Bertrand Moore Jr.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On May 15, 2026 at 11:15AM, Licensing Program Analyst (LPA), Rachel Vanegas arrived at Peace and Love Small Family Home (SFH) for the purpose of conducting a Case Management inspection visit regarding the Plan of Operation (POO). LPA met with Bertrand Moore Jr. - Caregiver. LPA spoke with the Licensee - Steven Johnson via phone who authorized Caregiver - Bertrand Moore Jr. to receive and sign this licensing report on the Licensee's behalf. On May 4, 2026, LPA Vanegas spoke with the Licensee via phone regarding the SFH's current client census. LPA Vanegas was informed by the Licensee that the Licensee had one client in care that was under 18-years-old (C1) and two clients in care that were Non-Minor Dependents (NMD), NMD1 and NMD2, and continuing to reside in the SFH through extended foster care at the time of the phone call. LPA Vanegas requested clarification regarding the two non-minor dependent clients in the SFH. During LPA Vanegas' inspection, LPA Vanegas was informed by Caregiver - Bertrand Moore Jr. that an update was received by the Licensee stating that NMD2 was no longer in placement as of April 24, 2026 and the Licensee was just informed by NMD2's county social worker of NMD2's discharge from placement on May 14, 2026. Per caregiver, Bertrand Moore Jr. NMD2 left placement as of April 12, 2026 and had not returned. LPA Vanegas observed a hole in the wall in the upstairs loft and a broken drawer in the upstairs client restroom. Per caregiver, Bertrand Moore Jr., the Licensee will contact the handyman for repair. Caregiver Bertrand Moore Jr. stated that the observed hole in the wall had occurred about three weeks ago and the date of the broken drawer was unknown at the time of this inspection. **Continued on the next page** Based on interview, observation, and record review, the Licensee is being cited two Type B violations. One Type B violation is in accordance with California Code of Regulations (CCR) Section 80010(a) Limitations on Capacity and Ambulatory Status for operating beyond the conditions and limitations specified on the license. One Type B violation is in accordance with CCR Section 80087(a) Buildings and Grounds for the broken drawer in the upstairs client restroom and the hole in the wall in the upstairs loft. An exit interview was conducted, and a copy of this report, LIC 811, and appeal rights were reviewed and provided to the Bertrand Moore Jr. - Caregiver.

Deficiencies:
80010(a): A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.

title:
1
2
3
4
5
6
780010(a) Limitations on Capacity and Ambulatory Status


summary: Facility Evaluation

raw_content:
Narrative:
On November 15, 2024, at 9:30AM, a Component II Office Visit was held to discuss the application received for Pean Small Family Home located at Sassafras Court, Canyon Country, CA 91387. Attending Component II were the following individuals: Anne Thiongo and Peter Kihumbu, Applicants, Kim Dear, Licensing Program Analyst, and , Bernice Karnsrithong, Licensing Regional Manager. The purpose of this Component II meeting was to review and discuss the incomplete application and pending Guardian Background clearances. A copy of this report was provided to the Licensees.

met_with: Peter Kihumbu and Anne Thiongo- Licensees


summary: Facility Evaluation

raw_content:
Narrative:
On December 20, 2024, at 9:30AM, Licensing Program Analyst, (LPA), Kim Dear and Licensing Program Manager, (LPM), Enrique Hernandez, arrived at Pean Small Family Home for the purpose of conducting a Pre-Licensing Inspection. LPA and LPM met with Anne Thiongo and Peter Kihumbu, Licensees who granted access to the home and provided a tour of the home. A health and Safety inspection was conducted upon entrance onto the property. The home will provide care and supervision to four (4) developmentally disabled children, male and female, ages 3-17 years, ambulatory only. Currently the census is zero (0). The home has no bodies of water on the premises. LPA observed the following during the inspection: : This home is a two story home five (5) bedrooms, four (4) bathrooms, living room, dining room, family room, kitchen, laundry room, a detached three (3) car garage, and a backyard. There are eleven (11) total dual carbon monoxide and smoke detector units and three (03) fire extinguishers are located throughout the home: (1) Kitchen, (1) Laundry room and (1) in the garage. The first floor : Kitchen: Equipped with a five (5) eye burner gas stove, tested for operation, adequate eating utensils , microwave, refrigerator/freezer, and a dish washer. There is a mid sized table with seating for six. There is wooden wall cabinet that is locked and can be opened with a key and/ or magnet for the medication. Cabinet area stores knives and are locked. In lower drawer, kitchen and the cleaning supplies are stored in a locked cabinet under the sink. See 809C Dining Room: Seating for 8-10 people around a large wooden table and (2) two end tables. Family Room: Consists of (3) large sectional sofas, a large TV, a non- operational electric fireplace with locked glass. All furniture is in good repair. Guest Bedroom : Has queen sized bed, toilet, shower, double sink, adequate lighting, and (2) night stands. 1st. Bathroom: Bathroom has double sink, a shower, and flushing toilet. Locked cabinet has four (4) drawers for extra linens, towels, and extra personal hygiene products for clients. Hallway: There is a second closet and cabinet for licensee personal clothing items. Personal Rights, the Grievance process, Disaster Plan, Discipline Policies and Procedures were displayed in hallway. Currently, all adults in the home have a Criminal Clearance on file with Community Care Licensing Division. Seating Area: (2) Large sofas , seating areas small round table and a large ottoman and a china cabinet. Second Floor/ Interior: Play Room: Equipped with two (2) large sofas, a mid- sized sofa, piano, television, easel/ dry- erase board, desk with chair. Balcony with locked door, accessible by door with screen. Master Bedroom: Occupied by Licensee. Equipped with a king-sized bed, sink, shower, jacuzzi, dresser drawer, adequate lighting, and a window. 2nd. Bathroom: Bathroom has a shower and tub feature, window, trash can with lid, and flushing toilet. Bedroom # B: to be occupied by Client. Equipped with a (2) twin sized beds, dresser drawer, lighting, and a window. Bedroom # C: to be occupied by Client. Equipped with a (2) twin- sized bed, dresser drawer, adequate lighting, and a large window. 3rd.. Bathroom: Bathroom has a shower and tub feature, window, trash can with lid, and flushing toilet. See 809C Laundry Room: Equipped with an operable washing machine and dryer, fire extinguisher. Cabinets store laundry supplies and some cleaning agents. Door entrance has lock operated by fingerprint / or code on door knob. Office Area: Equipped with a desk, computer station, locked cabinet for staff/client files. Playroom: is equipped with large television, sofas, adequate lighting and age-appropriate toys and games. There is also access to balcony. Door remains locked. All furniture is in good repair. Garage/ Exterior:: Is detached from home. Garage area remains locked and is only accessible to the Licensees and is inaccessible to residents. A toolbox, refrigerator and storage shelves are also present. tools are also located in this area. (2) Bar- B- Que grills, (1( Propane and the other charcoal burning. Water hose is stored in a closed container. Licensee registered (2) two vehicles for transportation. A Honda van, and a Acura. The water temperature was recorded at 70 degrees. (Water heater currently being replaced at the time of the inspection. Back& Front Yard/ Exterior: Yard is free of debris and hazards. The water shut off valve is located at the front of the home. The home has no bodies of water on the premises. Transportation Vehicles: Honda Odyssey and Acura Both vehicles are registered and are insured. Registration for both vehicles are verified current. The insurance coverage with Geico expiring May 21, 2025. Vehicles were inspected for working seat belts, front and back brake lights, blinkers, horn, to be in working order. auto Insurance policies, first-aid kit and a charged fire extinguisher, (optional). LPA observed the facility to be clean, safe and sanitary. Pathways , stairwells inclines, ramps, and open porches, are unobstructed. LPA shared reporting instructions for incident reporting,Law Enforcement contacts, a direct reporting link, about reporting all changes to within the facility to Community Care Licensing and any other appropriate agency. as well as the time frame for reporting. LPA informed the licensing that a Component III Tele- orientation will be scheduled per Community Care Licensing procedures An exit interview was conducted and a copy of this report was left at the facility.

met_with: Anne Thiongo/ Peter Kihumbu


summary: Facility Evaluation

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Narrative:
On June 19, 2025, at 9: AM, Licensing Program Analyst (LPA), Aimee Moratalla and Licensing Program Manager (LPM), Enrique Hernandez arrived at Pean Small Family Home for the purpose of conducting a Post Licensing Inspection. LPA and LPM met with Licensees, Anne Thiongo and Peter Kihumbu who granted access to the home and together a tour of the interior and exterior of the home was conducted. The census today is zero (0) and living in the home currently are the Licensees, two biological children, and Adult 1. The home has no bodies of water on the premises. A health and Safety inspection was conducted upon entrance onto the property. The facility is set up as follows: This is a two-story 5-bedroom, 3-bathroom, home located in a residential area. The home consists of a living room, receiving room, dining room, kitchen, office area, laundry area, play room, a backyard, and garage. Family room: is equipped with a sectional sofa, a mounted flat screen television, and an electric fireplace that is locked. Living room: is equipped with two couches and a coffee table. Dining room: is equipped with a table that seats eight. Kitchen: is equipped with a refrigerator/freezer, a five (5) burner gas stove/oven (all burners were operational at the time of this inspection), dish washer, and a microwave. Sharp knives are kept locked in a kitchen drawer next to the stove. Cleaning supplies are kept in the laundry area equipped with a fingerprint lock. Report continued on LIC 809C. The kitchen also has an exit door that leads to the backyard. From the backyard there are two gated pathways that lead to the street. Office area located on the second floor: is equipped with table, chair, two monitors, and computer. Laundry area: is located on the second floor next to the office area and is equipped with a washer and a dryer. A fire extinguisher, and cleaning tools are stored in this area. Backyard: contains two barbeque grills, portable plastic table, and a water hose in a storage container. Garage: LPA observed the garage is used for storage, with TV, couch, a fridge that contain alcohol - secured with a lock; the door from the house always remains locked and is made inaccessible to children in care. Bedroom #1: is located on the first floor - for guests. The room is equipped with queen-sized bed, closet, dresser, and television, a working light, and two windows. This room was vacant at the time of the inspection. Bedroom #2: is located on the second, it's the master's bedroom (A). This room is equipped with king-sized bed, at the foot of the bed are toddler beds, a dresser, bathroom, two walk-in closets. The room contains a working light, windows. Bedroom #3: is located on the second floor (B). The bedroom is occupied by Child#1. The room is equipped with a bunk bed and the bottom part is detached and next to it is another twin bed, dresser, closet, a working light, and windows. Bedroom #4: is located on the second floor (C). The bedroom is occupied by Child#2. The room is equipped with bunk bed, closet, dresser, a working light, and windows. Bedroom #5: is located on the second floor (D). The bedroom is occupied by adult#1. The room is equipped with a bunk bed, closet, two dressers, a working light, and windows. (3) Bathrooms: one bathroom is located along the hallway on the first floor, second and third bathrooms are located on the second floor. The bathrooms contain a toilet, sink/s, and a combined shower/tub. The hot water was tested and found to be with 105-120 (F) Report continued on LIC 809C LPA observed one (2) fully charged fire extinguisher. The hallway on the second floor has cabinets which store extra linens. The smoke and carbon monoxide detectors were tested and found to be in working order. Medications are stored in a locked cabinet above the kitchen counter. Disinfectants and cleaning solutions are kept locked inside the laundry room. The home has a working telephone readily accessible to children in care. The First Aid Kit was checked and found to be complete. LPA observed the home to be clean, safe, and sanitary. Passageways, stairways, and hallways are unobstructed. The front and backyard were clean and free of debris. There are no bodies of water located on the premises. The water shut off valve is in the front of the home and the shut off valve for the gas and electricity are on the side of the home. LPA reminded Licensees to ensure to send a copy of the program statement, of the new car registration, and fire extinguisher maintenance tag, and the emergency disaster plan. To install lock on the door that leads to the garage, and to secure the television in the room. During the visit, 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 Small Family Home Licensure and Emergency Plan were met. The home currently has no staff or clients placed in the home. An exit Interview was conducted, and a copy of this report was left with the Licensee, Peter Kihumbu

met_with: Licensees


summary: Facility Evaluation

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Narrative:
On March, 2025, at 9: AM, Licensing Program Analyst (LPA),Miguel Gomez arrived at Pean Small Family Home for the purpose of conducting a Post Licensing Inspection. LPA Gomez met with Licensee, Peter Kihumbu who granted access to the home and together a tour of the interior and exterior of the home was conducted. The census today is zero (0) and living in the home currently are the Licensees, two biological children, and two assistant caregivers. The home has no bodies of water on the premises. A health and Safety inspection was conducted upon entrance onto the property. The facility is set up as follows: This is a two-story 5-bedroom, 4-bathroom, home located in a residential area. The home consists of a living room, family room, dining room, kitchen, office area, laundry area, play room, a backyard, and garage. First Floor Family room: is equipped with a sectional sofa, a mounted flat screen television, and an electric fireplace that is locked. Living room: is equipped with two couches and a coffee table. Dining room: is equipped with a table that seats eight. Kitchen: is equipped with a refrigerator/freezer, a five (5) burner gas stove/oven (all burners were operational at the time of this inspection), dish washer, and a microwave. Sharp knives are kept locked in a kitchen drawer next to the stove. Cleaning supplies are kept in the laundry area equipped with a fingerprint lock. The kitchen also has an exit door that leads to the backyard. From the backyard there are two gated pathways that lead to the street. Report continued on LIC 809C. Backyard: contains two barbeque grills, fire extinguisher, portable plastic table, and a water hose in a storage container. Area is clean of debris. Garage: LPA observed the garage is used for storage, with TV, couch, a fridge that contain alcohol - secured with a lock; the door from the house always remains locked and is made inaccessible to children in care. Bedroom #1: is located on the first floor - for guests. The room is equipped with queen-sized bed, closet, dresser, and television, a working light, and two windows. This room was vacant at the time of the inspection. Second Floor Office: is equipped with table, chair, two monitors, and computer. Laundry area: i next to the office area and is equipped with a washer and a dryer. A fire extinguisher, and cleaning tools are stored in this area. Bedroom #2: Master's bedroom (A). This room is equipped with king-sized bed, at the foot of the bed is a toddler bed, a dresser, bathroom, two walk-in closets. The room contains a working light, windows. Bedroom #3: (B). The bedroom is occupied by Child#1. The room is equipped with a bunk bed and the bottom part is detached and next to it is another twin bed, dresser, closet, working light, and windows. Bedroom #4:(C). The bedroom is occupied by Child#2. The room is equipped with bunk bed, closet, dresser, a working light, and windows. Bedroom #5: (D). Vacant. The room is equipped with a bunk bed, closet, two dressers, a working light, and windows. (3) Bathrooms: one bathroom is located along the hallway on the first floor, second and third bathrooms are located on the second floor. The bathrooms contain a toilet, sink/s, and a combined shower/tub. The hot water was tested and found to be with 105-120 (F) Report continued on LIC 809C LPA observed one (2) fully charged fire extinguisher. The hallway on the second floor has cabinets which store extra linens. The smoke and carbon monoxide detectors were tested and found to be in working order. Medications are stored in a locked cabinet above the kitchen counter. Disinfectants and cleaning solutions are kept locked inside the laundry room. The home has a working telephone readily accessible to children in care. The First Aid Kit was checked and found to be complete. LPA observed the home to be clean, safe, and sanitary. Passageways, stairways, and hallways are unobstructed. The front and backyard were clean and free of debris. There are no bodies of water located on the premises. Facility observed transportation vehicle to have current insurance and registration. During the visit, 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 Small Family Home Licensure and Emergency Plan were met. The home currently has no staff or clients placed in the home. An exit Interview was conducted, and a copy of this report was left with the Licensee, Peter Kihumbu

met_with: Peter Kihumbu


summary: Facility Evaluation

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Narrative:
On 9/13/21 at 11: AM Licensing Program Analysts (LPA) Mary Shelton and Robin Sullivan met with licensee Wanda Williams for a Component II Meeting. LPA Shelton discussed the following: The Small Family Home will have three Client Surety bond Handling of youth funds and allowances Updated Health Screening House Rules Grievance procedures CPI Training (crisis prevention and intervention A Pre-licensing inspection is scheduled for October 6, 2021 at 2: PM

met_with: Wanda Williams


summary: Facility Evaluation

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Narrative:
Licensing Program Analysts (LPA's) Mary Shelton, Shawndra Miles and Robin Sullivan made an announced Pre-Licensing inspection on October 19, 2021 at 1:30PM. During the inspection LPAs met with Administrator, Wanda Williams. LPAs conducted a walk-through of the facility inside and out. The small family home will have three clients, one which may be non-ambulatory. The facility has no clients at this time. LPAs observed four bedrooms, two bathrooms. All four bedrooms are single occupancy rooms. LPAs observed sufficient storage for personal items and clothing in each bedroom. Mattresses have proper linens, pillows, and bed covers. LPAs observed all required postings including COVID-19, Emergency Disaster Plan, and Personal Rights. The disinfectants/cleaning solutions are kept in a locked cabinet. The refrigerator temperature is at or below 45 degrees F the freezer temperature at or below 0 degrees. The kitchen is stocked with nonperishable foods for one week and fresh perishable foods three days minimum. There is a menu posted for the week on the refrigerator. There is a working telephone for the clients. The carbon monoxide detectors, smoke detectors, and fire extinguishers were observed current and operational. The first aid kit is stocked with all required items. The Common Room is furnished child friendly. The dining area has seating for four, furniture that is good condition. Medication centrally stored, locked/inaccessible to clients. Hot Water is between 105-120-degree F. Toilets, wash basin, bath, and shower fixtures are in good repair. Bathrooms were stocked with soap and paper towels. The laundry Facility has a working washer and dryer. The motor vehicle that is used for the clients is properly maintained, lights, tires, registration/insurance and working seat belts. The facility is pest free. The storage in the back yard, with yard supplies and paint is locked. A copy of this report will be left with Wanda Williams, Administrator. An exit interview was conducted

met_with: Administrator, Wanda Williams


summary: Facility Evaluation

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Narrative:
On 1/19/ Licensing Program Analyst (LPA) Jean Stidman conducted an unannounced inspection and met with Wanda Williams Licensee for the purpose of a Post -Licensing Inspection. LPA inspected the facility outside and inside. The home is a 4 bedroom, two bathroom home. The facility does not currently have any clients or staff. Only the licensee is in the home. LPA observed the facility has two fire extinguishers that have been serviced within the last 12 months, the water temperature is 105.5 degrees Fahrenheit. The facility has at least a 7 day supply of non-perishable foods and a 3-day supply of perishable food. All the sinks have soap and paper towels. The facility has PPE and a sign in sheet near the front entrance. The facility has a supply of extra linens. LPA observed the medications and sharp items are stored in a locked cabinet in the kitchen. LPA observed the facility license, emergency disaster plan, floor/exit plan, developmental disabilities rights are posted. No violations were cited. LPA conducted exit interview with Wanda Williams Licensee and LPA provided the Summary Report to Wanda Williams Licensee.

met_with: Wanda Williams Licensee


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Jean Stdman made an unannounced Annual inspection on 10/12/23 at 12:15pm. During the inspection LPA met with Wanda Williams Licensee who assisted with the inspection. LPA Stidman conducted a walk-through of the facility inside and out. There are no clients in placement and no staff employed. LPA observed the facility has four bedrooms, and two bathrooms. LPA Stidman inspected and/or reviewed the following: Physical Plant Posting of license yes Personal Rights yes Disinfectants and Cleaning solutions inaccessible yes Refrigerator Temperature at or below 45 degrees F 41 degrees Freezer Temperature at or below 0 degrees_-6 degrees Nonperishable Foods one week and fresh perishable foods two days minimum N/A Menu present and posted yes Working telephone yes Carbon monoxide detectors yes_Smoke Detector yes First Aid Kit fully stocked_yes Common Room available yes_ Dining area (enough seating, furniture good condition, not broke or damaged) yes_ Medication centrally stored, locked/inaccessible N/A Office (locked and privacy) N/A Hot Water between 105-120 degree F (Properly labeled if over 125 degree F_135.5 degrees_ Fire Extinguisher inspection date July 2023_Toilets wash basin, bath and shower fixtures in good repair/no leaks _yes Soap and Paper towels N/A No clients in placement_ Laundry Facilities(available, work assign dates) _N/A Bedrooms-required linen and furnishings _yes_ Motor Vehicle properly maintained, lights, tires, registration/insurance and working seat belts yes_ Facility free of vermin yes_ Locked Facilities (open locked storage sheds) yes Bedroom (required bedding/furniture, furniture in good repair) yes Disaster Preparedness Disaster and mass casualty plan updated and available_yes Quarterly Drills conducted and documented N/A No clients in placement Disaster preparedness supplies verified N/A Staffing/Volunteers no staff employed Client Records N/A. The facility's Annual Fees were reviewed for compliance in the regional office prior to the facility inspection. Facility citation violation of California Code of Regulations, Title 22, Division 6, regulation 80088(e)(1) Fixtures, Furniture Equipment and Supplies. An exit interview was conducted and a copy of this report was left with Wanda Williams Licensee


facility_name: PERKINS SMALL FAMILY HOME

summary: Facility Evaluation

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Narrative:
On 04/24/2024 at 10:30am, Licensing Program Analyst (LPA) Enrique Hernandez met with Diana Perkins/Prospective Licensee for the purpose of conducting a Component Meeting. The following matters were discussed: Checklist for Application and Supporting Documentation: Personnel and Client Records, Planned Activities, Continuing Requirements, Physical Environment, Records to be Maintained, Reporting Requirements, and Waivers and Exceptions. LPA provided Provider Information Notices (PINs) PIN 22-11-CRP, PIN 24-05-CCLD, PIN 23-06-CRP and PIN 21-01-CCLD. Children's Residential Program, care tools, HSC, Guardian and Title 22 regulations. The following is needed for License approval: 1. LIC 308 - DESIGNATION OF FACILITY RESPONSIBILITY • At least one individual must be designated as the authorized person of the facility to act in the licensee's absence. A Licensee Cannot Designate Him or Herself. The form must contain the original signatures of the applicants/licensees. The licensing agency will not accept photocopied signatures on this form. 2. Affidavit Regarding Client Cash Resources (Form LIC400) is missing. . Lic508- A13. LIC 508 or LIC 508D - CRIMINAL RECORD STATEMENT • One form each is required for the applicant or designee and administrator, if applicable to the licensing category (i.e., facility is required to have an administrator). There is no signature on the second Page. 4. New sketch THE FIRE CLEARANCE IS STILL PENDING. After the fire inspection is completed, LPA will schedule a pre-licensing inspection. Meeting end at 11:45am

met_with: Diana Perkins/Prospective Licensee


facility_name: PERPETUA SMALL FAMILY HOME

summary: Facility Evaluation

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Narrative:
On 8/8/23 at 11: AM Licensing Program Manager (LPM) Ann Valenzuela and Licensing Program Analyst (LPA) Jacqueline Garcia began a Pre-Licensing inspection for a Small Family Home license. LPM and LPA met with applicant Inima Jackson led a tour of the home. The facility was toured both inside and out with the applicant. Applicant is applying for a capacity of 2 ambulatory clients. The home reside in an apartment complex with multiple units the apartment is upstairs and consists of: Bedroom #1, It was furnished with two twin beds. It sleeps two residents and has ample storage space. Bedroom #2, The room consisted of a queen bed and a toddler bed. It will sleep two family members Bedroom #3, The master bedroom was furnished with a king-sized bed. It sleeps applicant and spouse. The front door opens to the living room which is adjacent to the dinning and kitchen area. The balcony is located next to the dinning area. The hallway connects the the two bathrooms and 3 bedrooms. Bedrooms are arranged so that no more than two children share a room, and there is one child per bed. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There is adequate drawer and closet space for children's belongings. The smoke detectors were checked and were working properly. Telephone service and appliances were in a working order. All hazardous items will be made properly made inaccessible to areas where children will have access. The medication will be locked in a medication box in the hallway cabinet.. Cleansers/chemicals will be locked and stored in the lower cabinet (kitchen) and lower cabinet (bathroom) and hallway cabinet. Sharp knives will be locked and inaccessible and stored in a box locked in the upper kitchen cabinet. There were no guns or weapons as stated by applicant at this time. The hot water temperature was tested and noted to be above regulations (126.6) degrees and applicant will lower temperature. Proper storage of all food was discussed. Trash cans for storage of solid waste have tight fitting lids. First Aid kit were accessible with all required items and it was in the kitchen cabinet. A Fire extinguisher was observed and properly charged. The Facility Sketch, Emergency Disaster Plan, visitation policy will posted along with the Personal. where children will have access to play was completely fenced and free of hazards. There are no deficiencies to be cited at this time. The request to be licensed will be followed upon receive of corrections for small family home will be forwarded to Licensing Program Manager for final approval. An exit interview was conducted. A copy of this report was provided to Applicant/Licensee

met_with: Inima Jackson-Applicant


summary: Facility Evaluation

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Narrative:
On 10/12/23 at 10: AM Licensing Program Analyst (LPA) Jacqueline Garcia and Guadalupe Munoz conducted an announced visit to follow up on the previous Pre-Licensing inspection for a Small Family Home license that took place on 8/8/23. LPAs met with applicant Inima Jackson and took a tour of the home. Applicant is applying for a capacity of 2 ambulatory clients. The home reside in an apartment complex with multiple units the apartment is a second floor unit. See Prelicensing visit on 8/8/23 for details. The following items required follow up: Physical Plant - No Deficiency: 80087(g) - chemicals need to be locked under the sink Physical Plant - No Deficiency: 80076(a)(16) - bathroom under the sink needs a lock Physical Plant - No Deficiency: 80075(k)(1) - medication cabinet needs to be locked Physical Plant - No Deficiency: 80088(e)(1) - 126.6 needs to be lowered to max Physical Plant - No Deficiency: 83088(c) - one twin bed needs a mattress protector pad Operational Requirements - No Deficiency: 80022(a) - place files in the locked medication cabinet All above Physical Plant items meet regulations. Temperature observed was 105 degrees which falls within the required range of 105-120 degrees. There are no deficiencies to be cited at this time. The request to be licensed for small family home will be forwarded to Licensing Program Manager for final approval. An exit interview was conducted. A copy of this report was provided to Applicant/Licensee