facility_name: SERENITY HOME

summary: Facility Evaluation

raw_content:
Narrative:
On June 23, 2022 at 2:47pm, Licensing Program Analyst (LPA) Adrian Mendez conducted an unannounced Annual Required Inspection and met with Direct Support Professional (DSP), Danilo Habab. LPA disclosed the purpose of the inspection and was granted entry into the facility by the DSP staff. The facility was toured inside and out with facility DSP, Danilo Habab. The home is a one story residence with four bedrooms and two bathrooms. Bedrooms are arranged so that no more than two clients share a room, and there is one client per bed. There is adequate shelf and closet space for client's belongings. The bathrooms were clean and in good repair. The hot water in the client bathroom was measured to be 117.3 degrees. All hazardous items have been properly made inaccessible to areas where clients will have access. The medications were stored and locked in a cabinet in the kitchen. Cleansers/chemicals are locked and stored in a locked cabinet in the kitchen. Sharp knives are inaccessible and stored in a locked cabinet in the kitchen. The First Aid Kit is located in the locked medicine cabinet and contained all required supplies. The facility's smoke/carbon monoxide detectors in the hallway were checked and were operable. There are no guns or weapons in the facility as stated by Administrator, Henry Balanza. The following required posted items were observed accessible to clients: Facility License, Grievance Procedures, Personal Rights, Ombudsman Poster, Visitation policies, Emergency Disaster Plan and current menu. Clients medications were observed to be inaccessible and stored in a locked cabinet in the kitchen. The medication logs are kept updated and the dispensing records had no discrepancies. LPA observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There was a variety of snacks available for clients as well. The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. There are no bodies of water on the property. Cont. on 809-C A sample of client and staff files were reviewed during the inspection. All staff that work at the facility have Department of Justice and Child Abuse Clearance Index clearances. A review of administrative records indicate that the facility has paid their current licensing fees. Based on the facility inspection and file reviews this date, there are no deficiencies found at this time. A copy of this report was reviewed and provided to Administrator Henry Balanza.

met_with: Henry Balanza


state: CA

summary: Facility Evaluation

raw_content:
Narrative:
On November 10, 2022, at 9: AM Licensing Program Analyst (LPA) Eduardo Barragan conducted an announced annual facility inspection. LPA met with Merida Valanza, Administrator who provided LPA Barragan a guided tour of the facility both indoors and outdoors. The facility is a four-bedroom two bathroom (for client use) in this single story home; however, there were two other bedrooms where two Caregivers reside. The home consists of six bedrooms, two bathrooms, dining room, kitchen, a two car garage which is used as a laundry/storage room instead of garage. All clients had their own bedrooms, beds and storage areas. All beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. There is a backyard as well which is free of debris. There was a swing set accessible to the clients in the backyard with 3-wheeler bikes. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. The hot water temperature was measured in the main bathrooms and kitchedn and is currently 111.0 degrees which is in ration. There are no cameras at this facility. Per facility Administrator, no firearms or weapons are allowed in the facility. LPA observed the following items posted Personal Rights, Grievance Procedures, Visitation Policy, Facility sketch, Activity Schedule, Menu, Staff Schedule and Emergency Plan. Continued... Prior to inspection LPA reviewed personnel files to ensure they contained all required documentation per Title Regulations. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. All licensing fees have been paid and are current at this time. Based on the facility inspection and file reviews there are no deficiencies found at this time per California Code of Regulations. A exit interview was conducted. A copy of the report was discussed and provided along with appeal rights to Henry C Balanza, Administrator.

report_type: Facility Evaluation

visit_type: Annual

met_with: Merida Valanza, Administrator and Henry C Balanza, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On December 27, 2023 at 10: AM Licensing Program Analyst (LPA) Babatunde Aborchie arrived at Serenity Home to conduct a required annual inspection of the facility. The facility was toured inside and out with Administrator Henry Balanza. There were clients and two staff in the house. The home is a one-story residence and consisted of: · Bedroom #1 furnished with a twin-sized bed, It sleeps a male client. C1 · Bedroom #2, furnished with a twin-sized bed. It sleeps a male client. C2 · Bedroom #3 furnished with twin size bed. it was used as a staff room. · Bedroom #4 furnished with twin size bed. It sleeps a male client. C3 · Bedroom #5 furnished with twin size bed. It sleeps a male client. C4 · Bedroom #6 furnished with twin size bed. It was used as a staff room. A dining room, a furnished living room with a fireplace, a kitchen, a pantry, a walk-in full bathrooms, and the game room/activity areas . All bedrooms were arranged so that no more than two children share a room, and there was one child per bed. No room was commonly used for other purposes other than a bedroom, and no bedroom serves as a passageway to another room. There were adequate drawers and for children's belongings. The smoke and carbon monoxide detectors were checked and were working properly. The laundry room was in the garage. The bathrooms were clean and in good repair. The hot water was measured to be 110 degrees. All hazardous items have been properly made inaccessible to areas where clients will have access. The kitchen had adequate cooking supplies and utensils. The medications were stored and locked in a cabinet in the kitchen. Cleansers/chemicals were locked and stored in the garage. Sharp knives were inaccessible and stored in a locked cabinet in the kitchen. The First Aid Kit was located inside the cabinet in the kitchen and contained all required items. The living room area had appropriate games and activities. All windows and screens were in good repair. There were no guns or weapons in the facility as stated by the administrator. The following required posted items were observed accessible to clients: Grievance procedures, personal rights, ombudsman poster, visitation policies, and current menu. Clients medications were observed to be inaccessible and stored in the kitchen cabinet. The medication logs were kept updated and the dispensing records had no discrepancies. LPA observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There was a variety of snacks available for clients as well. Two clients were in the house, non-verbal and were observed to be safe in the home. Additionally, two Staff were interviewed and no issues were found. The facility outside the grounds were also inspected and were observed to be clean and well maintained. Emergency exits were free from obstruction. Clients files were reviewed and the following documents were present: Independent Behavior Support Plan, Individual Program Plan, health records, LIC 621 and medical consent. Staff records including current crisis prevention intervention (CPI), First Aid and CPR were reviewed during the inspection. The facility emergency plan was also reviewed, and all staff had the Department of Justice and Child Abuse Clearance Index clearance. Based on today's inspection and observations, there were no deficiencies being cited at this time in accordance with Title 22, Division 6, Chapters 1, 5 and 6. A copy of this report was reviewed and given to the facility administrator Henry Balanza. An exit interview conducted and a copy of this report was discussed and provided to the administrator.


facility_name: SERENITY HOUSE

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
During the investigation confidential interviews with Client #1 (C1), Client #1 (C2), and staff members were conducted as well as review of incident reports and review of reports from the Department of Children and Family Services. Information obtained revealed a lack of evidence to support reported allegations. Both C1 and C2 (alleged victims of abuse), denied that neither the facility staffs nor residents at the facility have physically or sexually abused them. Minors remained consistent with denial of alleged abuse throughout the investigation. As to the allegation that a child had a gun in the facility, the investigation revealed on 01/04/2021, C2 was observed to have what appeared to be a gun in C2's pant waist band. Staff notified the police; the police responded and determined that the "gun" was a prop (replica) and not an actual firearm. The replica was discarded without incident. It was determined that the replica gun was obtained by C2 while on AWOL status (absent without permission). The incident was reported by the facility to the appropriate parties. As to the allegation concerning hand sanitizer and/or children having access to hand sanitizer, interviews revealed that the facility uses hand sanitizer on a regular basis throughout the facility to help keep control of the spread of germs and to help prevent the spread of COVID-19 according to the Center for Disease Control (CDC) guidelines. Administrator denies having concerns, incidents or major issues with the use of clients utilizing the hand sanitizer as directed. Due to a lack of evidence, the above-mentioned allegations cannot be substantiated at this time. Although the allegations may have happened or may be valid, there is not a preponderance of the evidence to prove or disprove that neglect or a lack of supervision resulted in a violation. Therefore, the allegations are determined Unsubstantiated. There were no deficiencies cited per California Code of Regulations, Title 22 during the investigation. A copy of this report was emailed to Administrator for signature.

Investigation Findings:
13On August 20, 2021 at 2: PM, Licensing Program Analyst (LPA), Regina Martin contacted Facility Representative to deliver findings concerning the above-mentioned allegations. LPA Martin spoke with Lupe Rodriguez, Facility Administrator via telephone to discuss the investigative outcome. The investigation was conducted by Community Care Licensing (CCL) Investigator Robert Kujawa and LPA Regina Martin. On January 11, 2021, CCL received complaint allegations concerning neglect/lack of supervision. It was reported that Client #1 (C1) (see LIC811, dated 8/20/2021) was sexually assaulted while at the facility; Client #2 was physically assaulted while at the facility; Client #2 had a gun in the facility and that children had access to hand sanitizer. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Regina Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: SERENITY HOUSEFACILITY NUMBER: VISIT DATE: 08/20/2021

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

report_type: Complaint Investigation

met_with: Lupe Rodriguez

complaint_status: unsubstantiated


raw_content:
Narrative:
Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has decided that the allegations of Facility phone is not working, and Minor has not been able to wash clothes is unsubstantiated but if any additional information is received this complaint can be amended and findings can be changed. PER California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), Chapter 7. Version 4, there are no deficiencies to be cited at this time. Exit Interview conducted, and a copy of this report was left with the Facility Administrator (FA).

Investigation Findings:
13On December 8, 2021 at 2:45pm, Licensing Program Analyst (LPA) Enrique Hernandez made an announce inspection at Serenity House for the purpose of concluding the investigation on the above allegations and to deliver the findings. LPA met with the Facility Administrator (FA) Lupe Rodriguez who granted access into the facility and together discussed the investigation details. Facility phone is not working During the investigation process, LPA Hernandez called the facility to conduct telephone interviews with clients and staff. LPA did not observe that the facility phone was not working. This was corroborated by the facility's staff and clients. Minor has not been able to wash clothes Despite the power outage in the laundry room during the facility's ongoing repairs. LPA Hernandez did not obtain statements to corroborate the allegation. During confidential interviews, clients said that staff volunteered to wash their clothes in the laundromat during the time of the repairs. Continue on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: SERENITY HOUSEFACILITY NUMBER: VISIT DATE: 12/08/2021

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


raw_content:
Narrative:
Facility staff speaks inappropriately to residents Confidential interviews confirmed that a member of the staff told the clients that they were cockroaches. Based on LPA interviews and record reviews, the preponderance of evidence standard has been met, therefore the allegations are found to be SUBSTANTIATED. A deficiency was cited to the facility for Physical Plant, Personal Rights Violation and Neglect/Lack of supervision Exit interview was conducted with the Administrator. Due to technical difficulties with the printer, Appeal Rights and a copy of this report will be send via e-mail to the licensee for signature. Staff not providing planned menus. During the confidential interviews there were conflicted statements. Some of the interviews stated that there is always food, and they follow what is on the menu, other interviews stated that clients only eat fast food. Based on the confidential interviews conducted and file review the allegations cannot be substantiated, Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. The Department has decided that the allegations are unsubstantiated, but if any additional information is received this complaint can be amended and findings can be changed. Exit interview was conducted with the Administrator. Due to technical difficulties with the printer, a copy of this report will be send via e-mail .

Investigation Findings:
13On November 29, 2021, at 10:15am Licensing Program Analyst (LPA) Enrique Hernandez arrived at the facility to deliver the findings of a complaint investigation. LPA Hernandez met with Lupe Rodriguez Facility Administrator (FA) and discussed the investigative findings. On March 22, 2021, the Department received a complaint alleging Facility is in disrepair, Staff are not meeting minors needs and Facility staff speaks inappropriately to residents. Confidential interviews were conducted with 7 staff and 3 of 3 clients. The following information was obtained during the course of the investigation: Facility is in disrepair Confidential interviews confirmed that the facility is in disrepair and is under construction with the clients present in the facility. Staff are not meeting minors Confidential interviews corroborated that facility staff fall asleep on the facility couch during the day. This was confirmed by the facility administrator who received video recorded by clients showing the staff sleeping on the couch. Additionally, confidential interviews confirmed that clients brought beer and drank inside the facility without staff noticing. Continue on LIC9099-C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: SERENITY HOUSEFACILITY NUMBER: VISIT DATE: 02/10/2022

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

met_with: Facility Administrator


raw_content:
Narrative:
continued from page A query of Zillow resulted that the property at this location is currently on the market and in pending sale status. An official eviction notice was not done (meaning the legal steps for doing an eviction was not taken), however the Landlord did leave a 60-day Notice to Vacate under the front door mat. AGPA Woodard has determined the preponderance of evidence standard has not been met. Therefore, the allegation is found to be unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Investigation Findings:
13On February 19, 2022 at 10:50AM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted a follow-up complaint inspection to deliver findings on the above allegation. Upon arrival, AGPA was greeted by Cecila Hernandez, Mental Health Rehabilitation Specialist. On December 28, 2022, CCL received a complaint allegation concerning an eviction notice given to the facility due to non-payment of the lease. The investigation included confidential interviews with reporting party and staff members. Supporting documentation provided did not support that payment was not received or that it was in fact paid. It was also reported that as a result of non-payment the homes were under foreclosure. AGPA queried the Housing of Urban Development (HUD) website and didn't see the homes listed under properties for sell and/or auction. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: SERENITY HOUSEFACILITY NUMBER: VISIT DATE: 02/19/2022

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

met_with: Cecilia Hernandez


raw_content:
Narrative:
Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. The Department has decided that the allegations are unsubstantiated. If any additional information is received this complaint can be amended and the findings can be changed. PER California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), Chapter 7. Version 4.0, there are no deficiencies to be cited at this time. Exit interview was conducted with the licensee, due to technical difficulties with LPA's printer the report will be email to the licensee.

Investigation Findings:
13On May 26, 2022, at 12:45pm Licensing Program Analyst (LPA) Enrique Hernandez arrived at the facility to deliver the findings of a complaint investigation. LPA Hernandez met with Lupe Rodriguez Facility Administrator (FA) and discussed the investigative findings. On March 29, 2021, the Department received a complaint alleging Uncleared staff providing care and supervision to minors. Confidential interviews were conducted with 5 staff and 3 of 3 clients. The following information was obtained during the course of the investigation: After reviewing the facility documentation and verifying through Guardian, it was confirmed that Staff #1 (S1) was not associated with the facility for 5 days while S1 was working at the facility. During confidential interviews and documentation received, it was confirmed that S1 worked at the facility during that time. Based on LPA interviews and record reviews, the preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. A deficiency and immediate civil penalty of $500 are cited Per California Code Regulation, Title 22, Division 6, Chapters 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) for criminal record clearance An exit interview was conducted with the Administrator. Due to technical difficulties with the printer, the appeal rights and a copy of this report will be emailed to the licensee for signature. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: SERENITY HOUSEFACILITY NUMBER: 425800479

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

met_with: Administrator


raw_content:
Narrative:
continued from LIC Confidential Interviews revealed conflicting statements whether or not the alleged perpetrator made comments about female staff and called the alleged victim names. On June 16, 2022, Facility Administrator provided a statement from a minor regarding the alleged perpetrator in summary that he didn't do the things that he was accused of, and the alleged victim made it up. AGPA Woodard has determined the preponderance of the evidence standard has not been met, and the personal rights allegation that staff speak inappropriately to minors in care is unsubstantiated due to conflicting stories as to whether or not staff person called minor names or spoke inappropriately about female staff in the presents of minors. A copy of this report was left with the facility. continued from LIC 9099-A Per Facility Administrator (FA) the alleged perpetrator is an independent contractor, however in review of staff file, he was employed and offered a position with Garza & Rodriguez Family Service's extending per diem employment, Monday - Friday, 7AM-3PM which was signed on November 3, 2021. On June 16, FA provided a copy of a Zelle payment to the alleged perpetrator in the amount of $700, and an invoice for services performed on March 2nd, 9th, 10th, 15th, 16th, 18th, and 20th. AGPA Woodard has determined the preponderance of the evidence standard has been met, and the neglect/lack of supervision allegation that staff did not provide appropriate supervision to minor's in care is substantiated due to staff person who provided care and supervision was not cleared to be in the facility. Per California Code Regulation, Title 22, Division 6, CHAPTERS 1, General Licensing Regulations, the following deficiencies were cited at the time of this inspection. (See LIC809-D) A copy of this report was left with the licensee and appeal rights were discussed.

Investigation Findings:
13On June 25, 2022 at 10: AM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard arrived at the facility for the purpose of delivering findings. Upon arrival, AGPA Woodard was greeted by Cecilia Hernandez, Interim Facility Manager. Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard and Licensing Program Analyst (LPA) Enrique Hernandez conducted the investigation into the above allegation. In total, five staff interviews were conducted and two client interviews. Alleged perpetrator was unavailable to be interviewed due to phone number not being in service. continue on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: SERENITY HOUSEFACILITY NUMBER: VISIT DATE: 06/25/2022

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


raw_content:
Narrative:
During the investigation it was disclosed that on March 28, 2022, it was reported that C1 overdosed on illegal drugs. However, it was revealed that at the time of the incident, C1 was using illegal drugs at a friend's house and not at the facility (Serenity House). Confidential statements obtained revealed clients denied using or bringing drugs into the facility other than marijuana. Statements revealed facility staff members conduct random room checks on an ongoing routine basis. It was also revealed that staff members further check clients upon their return from an unauthorized absence. Information obtained found that staff follow facility protocols and procedures for AWOLs upon occurrence. Statements obtained produced a lack of corroborating evidence to prove clients use illegal drugs while in the facility or that staff fail to prevent clients from leaving the facility without permission. Therefore, based on all information obtained during the investigation, the allegation is deemed unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. There are no deficiencies cited. Exit Interview conducted. A copy of this report was emailed to Facility Administrator for signature.

Investigation Findings:
13On October 28, 2022 at 12: PM, Licensing Program Analyst (LPA), Regina Martin contacted Facility Representative to deliver findings concerning the above-mentioned allegations. LPA Martin spoke with Lupe Rodriguez, Facility Administrator via telephone to discuss the investigative outcome. The investigation was conducted by Community Care Licensing (CCL) Investigator Dennis Douglas and LPA Regina Martin. On April 4, 2022, it was reported to CCL that staff failed to properly supervise minors in care and that Client #1 (C1) (see LIC811, dated 10/28/2022) overdosed on illegal drugs. The investigation consisting of confidential interviews with three clients, four staff members, assigned social worker for C1, complainant, contacts with Law Enforcement and review of related medical records and police reports, revealed a lack of evidence to support the alleged. (Continued on page 2- LIC9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Regina Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: SERENITY HOUSEFACILITY NUMBER: VISIT DATE: 10/28/2022

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


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
In addition, a Solvency Audit was completed by the Community Care Licensing Division Audit Section on 3/24/23, and findings from that report revealed that the facility bank records showed that there should have been enough funds to cover necessary facility expenses, but there was "excessive spending including foreign transfer fees, restaurants, and excessive amounts at Costco." Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 1, are being cited on the attached LIC 9099D. Exit Interview conducted, and a copy of this report was emailed and mailed to the administrator.

Investigation Findings:
13On June 6, 2023, at 2:50pm, Licensing Program Analyst (LPA) Nancy O'Connell contacted the former administrator Lupe Rodriguez ue to the facility being closed on10/31/22 for the purpose of concluding the investigation on the above allegation and deliver the finding. LPA O'Connell spoke with Lupe Rodriguez and discussed the investigative finding. On 2/1/23 the Department received a complaint alleging that staff behavior poses as a risk to the minors. During the investigative process, LPA O'Connell conducted confidential interviews with relevant parties and reviewed a completed Solvency Audit report for the facility organization. After reviewing all the statements and the information obtained, the above allegation is supported, as the confidential interviews confirmed that staff P1 was withdrawing facility funds for unapproved/personal expenses during his time of operation as the Board of Directors President for the facility. Also, the administrator confirmed that P1 was a primary signor of the facility bank account and was removing funds from the facility bank account for personal use. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nancy O'Connell LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: SERENITY HOUSEFACILITY NUMBER: VISIT DATE: 06/06/2023

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

met_with: Lupe Rodriguez, Facility administrator

complaint_status: SUBSTANTIATED


facility_name: SERENITY OASIS HOME

summary: Facility Evaluation

raw_content:
Narrative:
On October 21, 2025, at 10: AM, Licensing Program Analyst (LPA) Jose Gonzalez and Licensing Program Manager (LPM) Cheraki Davis began a pre-licensing inspection for Serenity Oasis Group Home license. LPA and LPM met with applicant Ramla Sahid who led a tour of the home. Currently there are no clients placed in the home. The applicant is applying to serve three ambulatory and one non-ambulatory clients ages 6 to 17. The home is a one-story building with four bedrooms and three bathrooms which are set up as follows: · Bedroom #1 has one full size bed, will sleep one client, furnished with 2 nightstands, 1 dresser, a desk with a chair. This bedroom is equipped with shower and restroom · Bedroom #2 has one full size bed, will sleep one client, furnished with 2 nightstands, 1 dresser, a desk with a chair. · Bedroom #3 has one full size bed, will sleep one client, furnished with 2 nightstands, 1 dresser, a desk with a chair. · Bedroom #4 (non-ambulatory) has one full size bed, will sleep one client, furnished with 2 nightstands, 1 dresser, a desk with a chair. This bedroom is equipped with shower and restroom. The bedroom has ramp leading to the gate for one non-ambulatory client. · Living room is furnished with an L shaped couch, a TV, two chairs and table. · Hallway closet is furnished with emergency kit supplies. · Hallway closet is used for storing bedding, clothing and other items. · In the hallway a half bathroom. **CONTINUED on LIC 809C*** · Therapy room is furnished with a chair and couch. · Laundry room with electronic key locked pad. All chemical and cleaning supplies are stored. A fire extinguisher in the laundry room. · Kitchen furnished with refrigerator. A drawer with utensils and cupboard bowls, cups and plates. A fire extinguisher is placed in the kitchen. Tarsh can with lid. · The Staff office is located between kitchen and dining area. Staff office is locked and furnished with a medication cabinet, desk, and mini refrigerator. Sharp knives are locked in the staff office. · Dining room is furnished with a table and six chairs. A cabinet with children's activities, first aid kit, and first aid book. A fire extinguisher is attached to the wall. · In the yard they have a swing set, a covered patio, and five planter boxes. · A great room/living room, kitchen, dining area, three bathrooms, an attached three car garage, a laundry room, storage closet, and the backyard. The Client's bedroom was arranged so that no more than two clients will share the 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 in every bedroom and one carbon monoxide detector located in the hallway. The smoke detectors and the carbon monoxide detectors were checked, and they were working properly. The home's central air conditioning module was located outside of the home on the side in the yard. The home's tankless hot water heater was located inside the garage. The appliances were in working order. All sharp knives were located and locked in the staff office. The client's files will be locked inside a locked file cabinet in the staff office. There was adequate food storage space. A proper storage of all food was discussed. A trash can for storage of solid waste had a tight-fitting lid and was located in the kitchen. The client bathroom also had a trash can with a working lid. Cleaning supplies were located in the garage in a locked cabinet. The water temperature of client bathroom #1 was observed to be 116.9 degrees Fahrenheit. The water temperature of the client bathroom #2 was observed to be 116.9 degrees Fahrenheit and the water temperature of the client bathroom #4 was observed to be 116.1 degrees Fahrenheit. Medications will be located in the staff office in a locked medication cart. The home's First Aid kit was accessible with all required items included and located in the kitchen/dining cabinet.*Cont Lic 809c* It was observed to be properly charged. Applicant stated there were no weapons/firearms in the home. LPA and LPM observed there were no swimming pool. The backyard where clients will have access to play was completely fenced. The facility has 15 second delay egress system. The facility carbon monoxide and smoke detector are hard wired and water sprinkler system throughout the home. The facility sketch, emergency plan, and client rights were posted on the wall by the front door. Activity schedule and meal menus were posted in the kitchen. LPA and LPM observed perishable and non-perishable foods. The following deficiencies were observed: -Paper towels and paper towel dispenser were missing in all four bathrooms. -Sensors on the sliding glass doors. -Trash cans lids were missing in all four bathrooms. The plan of corrections will be due 10/24/2025. The request for a license will be forwarded to Licensing Program Manager for final approval once the Plan of Corrections is cleared. An exit interview was conducted. A copy of this report was provided to Ramla Sahid.

visit_type: Prelicensing

met_with: Administrator Ramal Sahid


summary: Facility Evaluation

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Narrative:
On May 6, 2026, at 8: AM, Licensing Program Analyst (LPA) Lisa Bernabe accompanied by LPA Arreola made an unannounced visit to conduct a Post- Licensing inspection for Serenity Oasis Group Home license. LPAs met with Abdiaziz Hussen, Administrator who led a tour of the home. Currently there are three clients placed in the home. The home is a one story building with four bedrooms and three bathrooms which are set up as follows: Bedroom #1 has one full size bed, non- occupied, will sleep one client, furnished with 2 night stands, 1 dresser, a desk with a chair. This bedroom is equipped with shower and restroom. Bedroom #2 has one full size bed, is occupied by one client, furnished with 2 night stands, 1 dresser, a desk with a chair. Bedroom #3 has one full size bed, is occupied by one client, furnished with 2 night stands, 1 dresser, a desk with a chair. Bedroom #4 (non-ambulatory) has one full size bed, sleeps one client, furnished with 2 night stands, 1 dresser, a desk with a chair. This bedroom is equipped with shower and restroom. The bedroom has ramp leading to the gate for one non-ambulatory client. Living room is furnished with an L shaped couch, a TV, two chairs and table. Hallway closet is furnished with emergency kit supplies. Hallway closet is used for storing bedding, clothing, and other items. In the hallway a half bathroom. CONTINUATION on LIC 809C Therapy room is furnished with a chair and couch. Laundry room with electronic key locked pad. All chemical and cleaning supplies are stored in locked cabinet. A fire extinguishers located in kitchen and laundry room. The Staff office is located between kitchen and dining area. Staff office is locked and furnished with a medication cabinet, desk, and mini refrigerator. Sharp knives are locked cabinet in the kitchen. Dining room is furnished with a table and four chairs. In the yard they have a swing set, a covered patio, with table and chairs. The Client's bedroom was arranged so that no more than two clients will share the 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 in every bedroom and one carbon monoxide detector located in the hallway. The smoke detectors and the carbon monoxide detectors were checked, and they were working properly. The client's files were locked inside a locked file cabinet in the staff office. There was adequate food storage space. The water temperature was observed to be 118 degrees Fahrenheit. Medications is located in the staff office in a locked medication cart. The home's First Aid kit was accessible with all required items included and located in the kitchen/dining cabinet. Licensee stated there were no weapons/firearms in the home. LPAs observed there was no swimming pool. The backyard where clients have access to play was completely fenced. The facility sketch, emergency plan, and client rights were posted on the wall by the front door. Activity schedule and meal menus were posted in the kitchen. LPAs observed perishable and non-perishable foods. Based on observations made during the inspection, no deficiencies observed during today's visit. An exit interview was conducted, a copy of this report was provided to Abdiaziz Hussen.

met_with: Abdiaziz Hussen, Administrator


facility_name: SHANNON HOUSE, THE

summary: Complaint Investigation - Unsubstantiated

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Investigation Findings:
13On November 9, 2021, Licensing Program Analyst (LPA) was met by facility representative Ms. Lewis to conclude the investigation with regards to the above-mentioned allegation. During the course of the investigation, LPA conducted interviews of the witnesses which included facility staff, school personnel and minors in care. Witness statements indicated that staff did not and has not hit any minors in the facility. The minor involved in the incident originally reported that staff hit the minor, but during the LPA's interview of the minor, the minor recanted the statement. LPA was unable to interview one of the two staff implicated in the allegation. Therefore, due to a lack of evidence a preponderance of the evidence could not be found as the allegation was reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. No deficiencies observed or cited during this inspection. Copy of this report along with Appeals Rights were left at the facility with Ms. Lewis. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Wayne Aoki LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

met_with: Saundra Lewis


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Investigation Findings:
13Complaint Specialist C.K. Kinney(CS) traveled to Serenity Group Homes and met with Saundra Lewis to deliver findings of investigation. Investigator Lomeli conducted investigation that included review of documentation, interviews of staff, clients, and witnesses and due to inconsistencies in the information received could not reach a preponderance of the evidence the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. No deficiencies observed or cited during this inspection. Copy of this report and Appeal Rights left at Serenity Group Homes at conclusion of inspection. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Charles Kinney LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3


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Investigation Findings:
13On June 9, 2022, Licensing Program Analyst (LPA) Wayne Aoki conducted a complaint inspection at this group home for the purpose of informing the facility of the results of the investigation. LPA was met by facility representative, Ms. Lewis. During the course of investigating the allegations, LPA conducted interviews with staff and minors in care at the facility. Based on the confidential interviews, the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the above allegations occurred, Therefore, the above allegations are unsubstantiated. There were no deficiencies cited during this inspection. Exit interview conducted and a copy of the report along with appeals rights were provided to Ms. Lewis. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Wayne Aoki LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

met_with: Ms. Lewis


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Investigation Findings:
13Complaint Specialist C.K. Kinney(CS) traveled to Serenity Group Homes and met with Brenda McBee to deliver findings of investigation. CS conducted investigation that included review of documentation and confidential interviews. Based on the information received a preponderance of the evidence could not be found that the bruising was a result of any action or inaction by the facility staff. Although the allegation may or may not be valid, a preponderance of the evidence could not be found so the allegation is deemed Unsubstantiated. Copy of this report and Appeal Rights left at Serenity Group Homes at conclusion of inspection. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Charles Kinney LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

met_with: Brenda McBee


summary: Complaint Investigation - Substantiated

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Investigation Findings:
13On March 22, 2023, Licensing Program Analyst (LPA) Wayne Aoki conducted a complaint inspection at this group home for the purpose of informing the facility of the results of the investigation. LPA was met by facility Administration, Ashleigh Garrett. During the course of investigating the allegation, LPA conducted confidential interviews with staff and witnesses. Based on confidential interviews and information obtained during the investigation, there is a preponderance of the evidence to prove the above allegation is substantiated. The facility is being cited for a violation of the California Code of Regulations, Title 22, Division 6, Section 80078(a), Responsibility for Providing Care and Supervision. An exit interview was conducted with Ashleigh Garrett and a copy of this report, and appeal rights were provided. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Wayne Aoki LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SIERRA CASCADE AC/SC, E SHAW AVE FACILITY NAME: SHANNON HOUSE, THEFACILITY NUMBER: 107202484

met_with: Ashleigh Garrett


raw_content:
Investigation Findings:
13On October 10, 2023, Licensing Program Analyst (LPA) Wayne Aoki traveled to Shannon House to conclude the investigation with regards to above allegation. LPA was met by facility representative Brenda McBee. During the course of the investigation, LPA conducted confidential interviews with staff and minors and obtained documents. Based on these interviews and documents, although the allegation may have happened or is valid, there is not a preponderance of the evidence. Therefore, based on the above, the complaint is Unsubstantiated. There were no deficiencies cited during this inspection. A copy of this report and appeals rights were provided to the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Wayne Aoki LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3


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Investigation Findings:
13Complaint Specialist C.K. Kinney(CS) traveled to Serenity Group Homes offices and met with Jave McIntyre to deliver findings of investigation, CS and Investigator Jorge Jauregui conducted investigation that included review of documentation and confidential interviews. Based on inconsistencies in the information obtained, a preponderance of the evidence could not be obtained. Although the allegations may or may not have occurred or may or may not be valid, without a preponderance of the evidence the allegations are deemed Unsubstantiated. Copy of this report, LIC Confidential Names and LIC Appeal Rights left at agency at conclusion of inspection. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Charles Kinney LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Jave McIntyre


summary: Complaint Investigation - Substantiated

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Investigation Findings:
13Complaint Specialist C.K. Kinney(CS) traveled to Serenity Group Homes offices and met with Jave McIntyre to deliver findings of investigation, CS and Investigator Ruben Munoz conducted investigation that included review of documentation and confidential interviews. Based on the information obtained Investigator Munoz was able to establish a preponderance of the evidence that Staff member shared inappropriate photos with a client. This facility is being cited for violation of Health and Safety Code 1558(a)(2) Conduct Inimical. Copy of this report, deficiency citation, LIC Confidential Names and Appeal Rights left at Serenity Group Home offices at conclusion of inspection. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Charles Kinney LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, E SHAW AVE FACILITY NAME: SHANNON HOUSE, THEFACILITY NUMBER: 107202484


facility_name: SHINING ANGELS CARE HOME, INC

summary: Facility Evaluation

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Narrative:
On September 16, 2025 at approximately 3: PM Licensing Program Analyst (LPA) Zaria Turner and Licensing Program Manager (LPM) Connie Goldie conducted an in-person Component II Meeting in the office for the purposes of reviewing the A Documents, and Program Statement. Present during the meeting were LPA Zaria Turner, LPM Connie Goldie, Kylie Ann Paguio, Facility Administrator, Alma Paguio, Assistant Administrator, and Rodante Paguio, Facility Manager. Below is a summary of the topics that were discussed and the answers that were provided by the applicant: A Documents - LPA, LPM, and attendees present reviewed the A Documents. LPA and LPM informed the applicants of adjustments and additional information that needed to be included. Facility Administrator provided updated documentation during today's meeting. Program Statement Sections to be Revised/Updated - LPA, LPM and the attendees present reviewed the program statement. Sections reviewed and corrections needed included: (report continued on LIC 809-C) SECTION 3 · Missing Methods/Goals. · How will the program be accomplished? · How Children will be assessed? · What types of treatment will be provided? · How will results be measured? How often? · Include Sexual Orientation, Gender Identity, and Gender Expression (SOGIE) resources. SECTION 4 · Provide a sample daily activity schedule for one week, including weekends and holidays. (Must include social, recreational, and educational activities). SECTION 5 · Description of Services to Be Provided: Trauma Informed services, training goals, materials provided, education plan, number of hours per day, etc. SECTION 6 · Description of procedures used to identify and handle, medical, dental, and health care needs. · Administering psychotropic medications. SECTION 10 · Procedures for emergency discharge. SECTION 11 · Describe rules and regulations regarding visitation. SECTION 12 · Elaborate on program policy? SECTION 14 · Include a copy of your agency's Emergency Intervention Plan. · Include the name and qualifications of individual who designed the plan. · Include Emergency Response Services. (report continued on LIC 809-C) SECTION 15 · Include intervention. · Actions to locate youth. · Staff training plan. · Plan to notify youth's authorized representative. SECTION 16 · Include how youth and authorized representatives are informed of their rights to file a complaint. · Include how youth and authorized representatives receive copies of the written complaint and grievance procedures. · Outline the plan to have the Foster Youth Bill of Rights and information about the Foster Care Ombudsperson always visibly posted without obstructions in areas accessible to children and visitors in facility. · Establish procedures to periodically check in with children to remind them of their personal rights. · Explicitly call out the Foster Youth Bill of Rights instead of saying "youth's rights as spelled out in Section 87072 of the ILS." SECTION 17 · Include safeguard form. SECTION 20 · Please provide a copy of the inventory form . SECTION 21 · Missing section. · Specify hours the administrator will be at the home. · Address how you will notify CCL of any personnel changes. · Address how often. · Reminder: submit an LIC500 (Every time there is a schedule change/personnel change). SECTION 22 · Missing Section. · Include copies of resumes or job applications for all staff roles, provide letter of acceptance/commitment if they have not started the position. (report continued on LIC 809-C) SECTION 24 · Include trainee qualifications. · Include how special training needs are identified and met. SECTION 25 · Missing Section. · Include the LIC 309 form. SECTION 26 · Will you be accepting volunteers. SECTION 28 · Missing section. · Include LIC 999. SECTION 30 · Missing two board of director statements. LPA Turner and LPM Goldie offered up the opportunity for discussion and questions. Facility Administrator, Kylie Ann Paguio, provided physical revisions during today's meeting and advised that they would be sending updated digital copies of the program statement sections that needed revisions. LPA, LPM, and applicants present, coordinated a Pre-Licensing date of October 7, 2025, at 10: AM. LPA and LPM will be enrolling attendees in the online Component III meeting on October 8, 2025, at 1: PM. LPA and LPM thanked the attendees for their time and concluded the Component II Meeting.


summary: Facility Evaluation

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Narrative:
On October 7, 2025 at approximately 10: AM, Licensing Program Analyst (LPA) Zaria Turner made an announced visit with the purpose of conducting a pre-licensing inspection to the above Group Home (GH). LPA met with Facility Administrator, Kylie Ann Paguio, and a walk through of the interior and exterior was completed. The facility was clean, safe and kept free of obstruction. LPA observed the posting of License, Personal Rights, and Emergency Disaster Plan. The facility consists of 3 bedrooms, 1 client bathroom, 1 staff bathroom, office, kitchen, living room, dining room/family room, staff lounge, laundry room, utility room, and garage. Client room 1 is equipped with 1 twin size bed, bedding, 1 bedside table, 1 bedside drawer, and closet space for clothing and personal belongings. Client room 2 is equipped with 2 twin size beds, bedding, 2 bedside tables, 2 bedside drawers, and closet space for clothing and personal belongings. Client room 3 is equipped with 1 twin size bed, bedding, 1 bedside table, 1 bedside drawer, and closet space for clothing and personal belongings. The client and staff bathrooms at the facility are equipped with working toilets, shower/tub, and running water. Upon entry, there is a desk and chair, a medication cabinet, four filing cabinets, and an electric fireplace. The living room is equipped with two sofas, a coffee table, a storage stand, and two side tables.The dining room/family room is equipped with four bar stools, a dining table and six chairs, two sofas, a chair and foot rest, a side table, a TV, entertainment center, and electric fireplace. The utility room is equipped with a shelf where extra linens are stored. The garage is equipped with a TV and five filing cabinets where extra linen, toiletries, cleaning supplies, and toxic items are kept and locked away.There is one hall closet used for extra toiletries, linens, and supplies. Continue summary of inspection on 809-C There is one hall closet equipped with the HVAC (Heating Ventilation and Air Conditioning Unit). There is a washer and dryer located in the hallway with shelving on either side where extra linen, toiletries, and cleaning supplies are kept and locked away. Disinfectants/cleaning solutions are inaccessible to clients in care and locked, under the kitchen sink and shelves next to the laundry unit. The refrigerator temperature is at or below 45 degrees F. There is nonperishable food for one week and fresh perishable food for three days minimum. There are containers to place leftover food. Carbon monoxide and smoke detectors are in working order. Hot Water between 105-120 degrees F. Fire Extinguishers are up to date and in working order. The toilets, bathtubs, and shower fixtures are in good repair. Soap and paper towels are available to clients in care. The facility is free of vermin. The backyard contains a concrete area with a grill, 3 lawn chairs, a garden area, and the staff lounge. The staff lounge is equipped with a sofa and two filing cabinets. There is no pool on the premises. The following adjustments need to be made: Facility telephone on premises. Facility thermometer in First Aid Kit An exit interview was conducted with Facility Administrator, Kylie Ann Paguio, and a copy of this report was discussed and provided during today's inspection.

met_with: Kylie Ann Paguio, Facility Administrator


facility_name: SHIRLEY'S HOME

summary: Facility Evaluation

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Narrative:
On October 28, 2021 at 8: AM, Licensing Program Analysts (LPAs) Timika Martin and Jenny Mundo conducted an unannounced Annual Licensing Inspection at the facility. LPAs met with Administrator, Michael White. The facility currently has a Group Home (GH) license. The GH is licensed to serve up to four (4) ambulatory clients age 12 to 17 that provides services to developmentally disabled clients. There are two (2) ambulatory minors and currently in placement. The LPAs requested the following: Personnel Report LIC500, Client Roster, Board of Meeting Minutes, Clients and Staff Files. This facility is a two-story home with two (2) bedrooms upstairs, three (3) bathrooms, a kitchen, a staff office area located in the kitchen, a living room/dining room and a laundry room located in the garage. There are no bodies of water on the premises. There are no firearms or ammunitions in the facility. At 8: AM, LPAs conducted a walkthrough of the entire facility. Physical Plant The license, facility sketch, personal rights, emergency disaster form, complaints poster, emergency phone numbers and food menu are posted in a prominent, publicly accessible location in the facility. Disinfectants and cleaning solutions are kept inaccessible stored and locked in the garage. Sharps/knives were also inaccessible and stored in downstairs cabinet. Facility has non-perishable food for at least one week and perishable food for at least two days. Medications are centrally stored in a locked cabinet downstairs which had a locked door. Smoke and carbon monoxide detectors were tested and in proper working order. Fire extinguishers were fully charged. First Aid Kits were checked and found to be complete. Room temperatures are maintained at 76 degrees F. The hot water temperature was tested and measured at 116.6 degrees F. All sinks, showers and toilets were in working order. No more than 2 children share a bedroom. All beds are in good repair; equipped with good springs, clean mattresses and pillows. Adequate supply of beddings and linens were observed. Facility provides age-appropriate clothing items and hygiene products. Overall, facility is clean, safe, sanitary and in good repair. Operations Facility maintains a register of clients and the register is available upon request. The board of directors regularly conducts meeting to review and discuss the GH's operation. The facility administrator and manager are the responsible and capable staff for communicating with emergency personnel in the facility. The facility has developed, maintained and implemented written complaint procedures. Disaster Preparedness Plan Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts disaster drill at least monthly for each shift. The drills are documented, and the documentation is maintained in the facility for at least a year. Facility maintains an emergency and disaster plan, register of clients, Needs and Services Plan for each client, medication records, and contact information for each client's responsible party and physician. Emergency Intervention Plan LPA's reviewed the facility's emergency intervention plan. Facility have not used any manual restraints yet but will keep a monthly log of each use of manual restraints that contains all required information when needed. Facility has an emergency intervention training curriculum. All five (5) staff members are trained on the facility's emergency intervention procedures. Client Records LPAs reviewed two (2) client records. All client records are available to the licensing agency to inspect, audit and copy upon demand. Client records contain required information including, but not limited to, consent forms, court orders, needs and services plan, removal/discipline/complaint procedures; medical assessment; safeguards for cash resources, personal property and valuables; education records; personal rights forms; and medication administration records. Staff Records LPAs reviewed three (3) staff records. All staff have been subjected to criminal records review and have been fingerprinted and cleared with DOJ, FBI and CACI. The administrator meets the required qualifications and/or experience. Documentation of the required education and experience requirements are maintained in the personnel file. Facility Managers meet requirements. LPAs verified 40 hours of annual training for direct care staff. Clients with Special Health Care Needs LPA's reviewed the section of Children with Special Health Care Needs; no deficiencies were observed. There are currently no clients in care with special health care needs. LPAs interviewed one (1) staff. There are no citations assessed during this inspection. The administrator was provided information on where to locate the Provider Information Notices (PINs), guidance to the new CARE Tools inspection process and Guardian. An exit interview was conducted, and a signed copy of this report, LIC811 and appeal rights were provided to the facility administrator.

met_with: Michael White, Administrator


summary: Facility Evaluation

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Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Gilbert Gutierrez and Pamela Silva on July 25, 2022. During the inspection, LPAs met Michael White, Administrator who provided the tour of the facility. At the time of the inspection, there were two clients present in the facility. LPAs conducted a tour of the facility at 9:10AM. The facility is clean, safe, sanitary and in good repair. All medications are centrally stored, locked in inside a cabinet in the hallway and accessible only to staff responsible for medications. Out of two (2) clients, only C1 is dual placement. LPAs reviewed C1's file at 9:30am. LPAs observed during records inspection that each psychotropic medication is not documented on a separate PMAR. However the psychotropic medications are being tracked on the MAR. LPAs reviewed a total of two staff records at 10:00am. LPAs interviewed two staff at 10:45am. C1 was not interviewed due to cognitive disability. No deficiency citations issued at the time of the inspection. However, one technical violation was issued (see LIC TV). An exit interview was conducted and copy of this report, LIC TV and LIC 811 were provided to Administrator, White

visit_type: Case Management

met_with: Michael White


summary: Facility Evaluation

raw_content:
Narrative:
On September 7, 2023 at 9: AM, Licensing Program Analyst (LPA) Gilbert Gutierrez, conducted an annual/required inspection to the facility and met Michael White, Administrator. The facility is a two--story condominium unit with two bedrooms and three bathrooms and attached garage. Currently there are two clients placed in this facility. LPA obtained a copy of clients' roster, LIC 500 (Personnel Report), Emergency Disaster Plan. Surety Bond, Board Meeting MInutres. LPA reviewed the Property and Incidental (P&I), and Emergency Drills log. Physical Plant LPA started the inspection at about 9: AM. Administrator White toured this LPA inside the facility. LPA observed the following: the posted license, emergency disaster plan, personnel schedule, client personal rights, Foster Youth's Bill of Rights. The disinfectants, cleaning solutions, sharp objects are locked inside a cabinet. The facility maintains supplies of non-perishable foods for at least a week and perishable foods for at least two days. Each bedroom has a single bed in good repair with clean sheets and linens, five drawers and closet space for the client's clothing. There were extra linens, adequate towels and hygiene supplies. Only one client sleeps in a room. No room commonly used for other purposes is being used as a bedroom. The window screens are in good repair and free of dirt. There were lights in the rooms and throughout the facility. All medications were stored locked in a cabinet located in the hallway. There was a working land phone in the facility. The first aid kit was complete and readily available. The smoke/carbon monoxide detectors were in working order. The water temperature was tested using a digital thermometer and registered 107.1 degrees. cont. Staff Records At 9: AM, LPA reviewed three staff records. All staff subject to criminal records review have been fingerprinted and cleared. There is documentation of the required education and experience requirements and training in the personnel file. The administrator and facility managers meet the required qualification and/or experience. Client Records At around 11: AM, LPA reviewed two client records. All client records are available to LPA to inspect, audit upon demand. Client records contain required information including, but not limited to, consent forms, Individual Program Plan (IPP), medical assessment, safeguards for cash resources, personal property and valuables, personal rights forms, and medication administration records. LPA interviewed 1 staff in the facility. A deficiency citation is issued at the time of the inspection. A copy of the LIC 809, LIC 809C LIC 809D, LIC 811s, and LIC 9102 were provided to the administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On October 9th, 2024 at 9:15AM, Licensing Program Analyst (LPA) Olena Maico and Licensing Program Manager Tira Logan, conducted an annual/required inspection to the facility and met with Michael White, the Administrator. The facility is a two-story condominium unit with two bedrooms and three bathrooms and attached garage. Ther is a small outdoor area with the table and chairs for clients' use. The facility currently has a Group Home (GH) license. The GH is licensed to serve up to four (4) ambulatory clients age 12 to 22 with developmental disabilities. There are two (2) ambulatory minors and currently in placement. This facility is a two-story home with two (2) bedrooms and 2 bathrooms upstairs, one staff bathroom downstairs, a kitchen, a staff office area located in the kitchen, a living room/dining room and a laundry room located in the garage. There are no bodies of water on the premises. There are no firearms or ammunition in the facility. LPA obtained a copy of clients' roster, LIC 500 (Personnel Report), Emergency Disaster Plan and LPA reviewed Emergency Drills log. Physical Plant LPA started the inspection at about 9: AM. Administrator White toured with LPA inside the facility. The license, facility sketch, personal rights, emergency disaster form, complaints poster, emergency phone numbers and food menu are posted in a prominent, publicly accessible location in the facility's kitchen/hallway area. The disinfectants, cleaning solutions, sharp objects are locked inside a cabinet. The staff and clients' files are securely locked in the cabinets. The facility maintains supplies of non-perishable foods for at least a week and perishable foods for at least two days. Each bedroom has a single bed in good repair with clean sheets and linens, five drawers dressers and closet space for the client's clothing. There were extra linens, adequate towels and hygiene supplies. Only one client sleeps in a room. The window screens are in good repair and free of dirt. There were lights in the rooms and throughout the facility. All medications were stored locked in a cabinet located in the hallway. There was a working land phone in the facility. The first aid kit was complete and readily available with all required non-expired items. The smoke/carbon monoxide detectors were in working order. Fire extinguisher is up to date (renewed January 2024) and fully charged. The water temperature was tested using a digital thermometer and registered 107.1 degrees. Operations Facility maintains a register of clients and the register is available upon request. The board of directors regularly conducts meeting to review and discuss the GH's operation. Meeting minutes were not available for LPA to review, and the Administrator will email those to the LPA. The facility has developed, maintained and implemented written complaint procedures, which is documented in clients' files. Disaster Preparedness Plan Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts disaster drill at least monthly for each shift. The drills are documented, and the documentation is maintained in the facility for at least a year. Facility maintains an emergency and disaster plan, register of clients, IPP for each client, medication records, and contact information for each client's responsible party and physician. Emergency Intervention Plan LPA's reviewed the facility's emergency intervention plan. Facility have not used any manual restraints yet but keeps log of use of manual restraints if need arises. Facility has an emergency intervention training curriculum. All five (5) staff members are trained on the facility's emergency intervention procedures (CPI training ). LPA interviewed 1 staff in the facility. A copy of the LIC 809, LIC 809C , was provided to the Administrator. No deficiencies noted. LPA Will return to interview clients.

met_with: Michael White, Adiministrator


summary: Facility Evaluation

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Narrative:
On October 15th, 2024 at 16:40PM, Licensing Program Analyst (LPA) Olena Maico conducted a continuation of annual/required inspection to the facility and met with LAToya Gurley, Facility Manager. Note from the prior inspection: Administrator e-mail Board of Directors meeting minutes to the LPA for review. Also facility has 2 cameras - one is outdoor ring camera and one is in the common area/ living room. Living room camera is facing away from the private areas. Administrator was notify to add the camera information to the program statement and sent it to their LPA for review. Staff records LPA reviewed five staff records. All staff have been subjected to criminal records review and have been fingerprinted and cleared with DOJ, FBI and CACI. The administrator meets the required qualifications and experience. Documentation of the required education and experience requirements are maintained in the personnel file. Facility Managers meet requirements. LPA verified initial hours of training upon hire for direct care staff and 20 hours of annual training. Facility carries a log with hours logged for the staff training available to the LPA for review ( record were reviewed during the prior visit) Client Records LPA reviewed two client records. All client records are available to LPA to inspect and audit upon demand. Client records contain required information including, but not limited to, consent forms, court orders, IPP plans from the Regional center, removal/discipline/complaint procedures; medical assessment; safeguards for cash resources (including allowance distribution and expense records), personal property and valuables; education records; personal rights forms; and medication administration records (files were reviewed during prior visit) LPA returned for clients' interviews. LPA interviewed 2clients. A copy of the LIC 809, LIC 811 was given to the Facility Manager. No deficiencies have been found.

met_with: LAToya Gurley, Facility Manager


summary: Facility Evaluation

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Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Pamela Silva, Timika Martin and Juliet Robles on 11/18/24 at 9: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Administrator, Michael White and inspected the facility inside and out. LPAs reviewed zero (0) of child's records and three (3) of staff personnel files on site at the facility. LPAs reviewed zero (0) of child's psychotropic medications and medication records due to child being over the age of 18. LPAs interviewed one (1) of staff on site to discuss the facility's policies and procedures of operation. LPAs interviewed zero (0) of child currently prescribed psychotropic medication. No deficiencies are being cited at this time. LPAs conducted exit interview with Michael White, Administrator and provided a copy of this licensing report.


summary: Facility Evaluation

raw_content:
Narrative:
On October 31, 2025, Licensing Program Analyst (LPA) Johanna Aracena conducted an annual/required inspection to the facility and met with Michael White, Facility Administrator. The facility is a two-story condominium unit with two bedrooms, two and a half bathrooms and an attached garage. There is a small patio area with a picnic table for clients' use. The facility is currently licensed as a Group Home to serve up to four (4) ambulatory clients age 12 to 22 with developmental disabilities. There are two (2) ambulatory clients in placement at the age of 20 years old each. This facility is a two-story home with two (2) bedrooms and 2 full bathrooms upstairs, one half downstairs, a kitchen, a staff office area located in the kitchen, a living room/dining room and a laundry room located in the garage. There are no bodies of water on the premises. There are no firearms or ammunition in the facility. LPA obtained a copy of clients' roster, LIC 500 (Personnel Report), Emergency Disaster Plan and LPA reviewed Emergency Drills log. The license, facility sketch, personal rights, emergency disaster form, complaints poster, emergency phone numbers and food menu are posted in a prominent, publicly accessible location in the facility's kitchen/hallway area. The disinfectants, cleaning solutions, sharp objects are locked inside a cabinet and in the garage. The staff and clients' files are securely locked in the cabinets. The facility maintains supplies of non-perishable foods for at least a week and perishable foods for at least two days. Each bedroom has a single bed in good repair with clean sheets and linens, five drawers dressers and closet space for the client's clothing. There were extra linens, adequate towels and hygiene supplies. Only one client sleeps in a room. The window screens are in good repair and free of dirt. There are lights in the rooms and throughout the facility. All medications are stored locked in a cabinet located in the hallway. There is a working land phone in the facility. The first aid kit is complete and readily available with all required non-expired items. The smoke/carbon monoxide detectors were in working order. Fire extinguisher is up to date (renewed March 2025) and fully charged. The water temperature was tested using a digital thermometer and registered 107.1 degrees. Facility maintains a register of clients and the register is available upon request. The board of directors regularly conducts meeting to review and discuss the GH's operation. Meeting minutes were not available for LPA to review, and the Administrator will email those to the LPA. The facility has developed, maintained and implemented written complaint procedures, which is documented in clients' files. Disaster Preparedness Plan Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts disaster drill at least monthly for each shift. The drills are documented, and the documentation is maintained in the facility for at least a year. Facility maintains an emergency and disaster plan, register of clients, IPP for each client, medication records, and contact information for each client's responsible party and physician. The facility has 2 cameras - one is outdoor ring camera and one is in the common area/ living room. Living room camera facing towards the facility entrance and away from the private areas. LPA received facility's program statement amendment for review. LPA reviewed three (3) staff records. All staff have been subjected to criminal records review and have been fingerprinted and cleared with DOJ, FBI and CACI. The administrator meets the required qualifications and experience. Documentation of the required education and experience requirements are maintained in the personnel file. Facility Managers meet requirements. LPA verified initial hours of training upon hire for direct care staff and 20 hours of annual training. Facility carries a log with hours logged for the staff training available to the LPA for review. LPA reviewed two client records. All client records are available to LPA to inspect and audit upon demand. Client records contain required information including, but not limited to, consent forms, court orders, IPP plans from the Regional center, removal/discipline/complaint procedures; medical assessment; safeguards for cash resources (including allowance distribution and expense records), personal property and valuables; education records; personal rights forms; and medication administration records. LPA will return to conduct interviews due to clients not being at the facility at the time of the visit. Exit interview was conducted and a copy of this report provided to the Facility Administrator.

met_with: Michael White- Facility Administrator


facility_name: SIGNS OF LIFE GROUP HOME II

summary: Facility Evaluation

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Narrative:
On December 17, 2021 at 2:41pm, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Signs of Life Group Home II for the purpose of conducting an inspection to determine control of property by the licensee. LPA observed that no one was home. LPA observed property looks abandoned, No cars in the driveway. Window blinds closed. Outside neat and well kept. No access to enter through front gate. Gate locked. Observed trash cans on side of house. Documentary evidence (photos) Called licensee at (323) 756-7783 at 2:48pm. No answer. Only a busy signal. Does not appear to have control of property.


facility_name: SLEEPY CREEK

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Narrative:
Confidential interviews stated a witness observed the office door open, noticed "skin" of an individual lying on the office floor in front of the office bathroom door and also observed another figure with a deep voice. Confidential interviews stated S1 had sexual intercourse with C1 and charges will be filed against S1. Based on confidential interviews, the allegation that C1 was sexually abused while in care is substantiated. The preponderance of evidence standard has been met. Facility is cited for violation of California Code of Regulations, Title Division Six, regulation Personal Rights: (d)The licensee shall ensure that each child, regardless of whether the child is in foster care, is accorded the personal rights specified in Welfare and Institutions Code section 16001.9, as applicable. In addition, the licensee shall ensure that each child is accorded the following personal rights: (11)To be free from physical, sexual, emotional, or other abuse, and corporal punishment A copy of the report was discussed and provided along with appeal rights to Program Representative Selene Acosta.

Investigation Findings:
13On 06/01/2022, at 9:45 a.m. Licensing Program Analyst (LPA) Marisol Lopez arrived at the facility unannounced and met with Program Representative Selene Acosta, of Sleepy Creek to discuss the investigative findings for the allegation noted above. LPA Lopez spoke with Facility Director Tiffany Mileda, who authorized Program Representative Selene Acosta to sign. On 03/01/2022, Community Care Licensing's (CCL) Investigations Branch Bureau, Investigator Thomas Smith was assigned the investigation. On 3/02/ Investigator Smith conducted an initial complaint investigation and met with Facility Manager Devyn Moore. The investigation consisted of confidential interviews with one detective, six facility staff, one of two clients and review of documents: Incident reports and law enforcement documents. On 02/24/2022, the Department received an allegation that a minor was sexually abused while in care. It was reported that staff #1 walked client #1(C1) to the shower and raped C1. Confidential interviews stated S1 escorted C1 to an office bathroom which is off limits to clients, instead of the client bathroom in the hallway. (see continuation form LIC9099-C dated 06/01/2022) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Marisol Lopez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, METROPOLITAN DR. # FACILITY NAME: SLEEPY CREEKFACILITY NUMBER: VISIT DATE: 06/01/2022

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

met_with: Selene Acosta


summary: Facility Evaluation

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Narrative:
On October 18, 2021 at 11: AM, Licensing Program Manager (LPM), Natasha Dunlap and Licensing Program Analysts (LPAs) Jazmond Harris and Sarah Smith conducted a pre licensing inspection and component III orientation. LPM and LPAs met with Director of Operations, Tiffany Pineda, Director of Nursing, Clara Mahmoudi, Program Director, Melanie Morones Walker, and Facility Manager, Devyn Moore. The applicant is applying for a group home with the capacity of 6 ambulatory clients, mixed genders, ages 12-17 years old. This program provides services for private placement clients. The facility is a two story house with four bedrooms, six bathrooms, kitchen, dining room, two living rooms, laundry room, two staff offices, two private rooms, medical room, a gym and recreation room, which is located in the garage area. Sports equipment/toys/books/games were observed for client's recreation time. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. Emergency exits were free from obstruction. There is adequate indoor and outdoor activity space. The facility has a basketball and volleyball court. Medications will be locked in a closet in the medical room. The facility smoke detectors and carbon monoxide detectors were tested and were observed to be in working order; fire extinguisher is properly charged and serviced. The fire clearance has been approved. The facility has a fully equipped first aid kit and first aid manual. The facility does not have cameras. The applicants stated there were no weapons in the home. Cleansers/chemicals were stored and locked in laundry area and storage hallway. Sharp knives were made inaccessible and stored in the staff office. The following required forms were posted in the facility: Personal Rights, Grievance Procedures, Emergency Response, and Covid-19 related information. Per applicant, client and personnel files will be available electronically at all times for licensing request or review. All bedrooms are located upstairs and are set up as follows: Bedroom 1: designated for one client; has one full bed, one dresser drawer, and a night stand, Bedroom 2: designated for one client; one full bed, one dresser drawer, and a night stand. Bedroom 3: designated for two clients; has two full beds, two dresser drawers, and two night stands. Bedroom 4: designated for two clients; has two full beds, two dresser drawers, and two night stands. This is an amended 809C page to the original issued 10/18/2021. LPM and LPAs discussed with the applicant the need for portable closets to be installed in each room designated for clients. Applicant provide proof of closets prior to licensure. Due to the facility having separate floors and all client bedrooms are located upstairs, LPM and LPAs discussed signal system in accordance with Title 22 regulation 84088(e)(2). Per applicant, staff will be on each floor whenever children are present in lieu of installing a signal system. Each room has adequate clean linens, pillows, blankets, comforters, mattress pads, and mattresses. The hot water in the children's bathroom was measured and deemed to be safe. Facility has a pool which is appropriately and secured with a mesh fence. The enclosure was measured to be over 5 feet tall, with a self-latching gate that swings outward. The pool appeared to be cleaned and free of excessive debris. The facility has one van that will provide transportation for the clients. The applicant has been informed that the address to this facility is available to the public. All special incident reports (SIR's) will be sent via e-mail to: cclpaccr@dss.ca.gov. The reporting requirements were reviewed with the applicant on this date. The applicant was provided with an updated Facility Personnel Report Summary at the time of this visit and understands that once the license is approved, all employees and volunteers shall have an approved criminal record clearance for Community Care Licensing and be associated to this facility. All documents have been received according to Title 22 regulations. An exit interview was conducted with applicants and a copy of this report was printed and provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On December 07, 2021 at 12: PM, Licensing Program Analyst (LPA), Marisol Lopez conducted a post licensing inspection. LPA met with Program Director, Melanie Morones Walker. The group home has a capacity of 6 ambulatory clients, mixed genders, ages 12-17 years old. This program provides services for private placement clients. The facility is a two story house with four bedrooms, six bathrooms, kitchen, dining room, two living rooms, laundry room, three staff offices, one treatment room, medical room, a gym and recreation room, which is located in the garage area. LPA observed sports equipment/toys/books/games for client's recreation time. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. Emergency exits were free from obstruction. There is adequate indoor and outdoor activity space. The facility has a basketball and volleyball court. Medications are locked in a closet in the medical room. The facility smoke detectors and carbon monoxide detectors were tested and were observed to be in working order; fire extinguisher is properly charged and serviced. The facility has a fully equipped first aid kit and first aid manual. The facility does not have cameras. The applicants stated there were no weapons in the home. Cleansers/chemicals were stored and locked in laundry area and storage hallway. Sharp knives were made inaccessible and stored in the staff office. The facility has a pool with a fence at least five -feet high and meets requirements. All bedrooms are located upstairs and are set up as follows: Bedroom 1: designated for one client; has one full bed, one dresser drawer, and a night stand, Bedroom 2: designated for one client; one full bed, one dresser drawer, and a night stand. Bedroom 3: designated for two clients; has two full beds, two dresser drawers, and two night stands. Bedroom 4: designated for two clients; has two full beds, two dresser drawers, and two night stands. The following required forms were posted in the facility: Personal Rights, Grievance Procedures, Emergency Response, food menu plan and Covid-19 related information. Client and personnel files are available electronically at all times for licensing request or review. LPA reviewed Physical Plant, Operations, Disaster Preparedness, and Emergency Intervention. Due to time constraints, the annual inspection is being extended for staff and client file reviews and interviews. LPA conducted 0 of 3 staff interviews, 0 of 6 staff file reviews, 0 of 4 client interviews and 0 of 4 client file reviews. An exit interview was conducted, and this report was reviewed with Program Director Melanie Walker and a copy of this report was provided.

met_with: Melanie Walker


summary: Facility Evaluation

raw_content:
Narrative:
On December 08, 2021 at 10: AM, Licensing Program Analyst (LPA), Marisol Lopez conducted a continuation post licensing inspection. LPA met with Program Director, Melanie Morones Walker. The group home has a census of 4 ambulatory clients, mixed genders, ages 12-17 years old. This program provides services for private placement clients. . During the inspection, LPA conducted 3 of 3 staff interviews, 6 of 6 staff file reviews, 4 of 4 client interviews and 4 of 4 client file reviews. LPA reviewed the client electronic medication documents. LPA will follow-up to ensure that the electronic logs are in compliance with Title Regulations. An exit interview was conducted, and this report was reviewed with Program Director Melanie Walker and a copy of this report was provided.


summary: Facility Evaluation

raw_content:
Narrative:
On December 08, 2021 at 3: PM, Licensing Program Analyst (LPA), Marisol Lopez conducted a continuation post licensing inspection. LPA met with Program Director, Melanie Morones Walker. The group home has a census of 4 ambulatory clients, mixed genders, ages 12-17 years old. This program provides services for private placement clients. . On 12/08/21 at 3:30 pm, LPA completed the inspection tool. LPA will follow-up to ensure that the medication electronic logs are in compliance with Title Regulations. An exit interview was conducted, and this report was reviewed with Program Director Melanie Walker and a copy of this report was provided.


summary: Facility Evaluation

raw_content:
Narrative:
On October 26, 2022 at 10:00 a.m., Licensing Program Analyst (LPA) Marisol Lopez and LPA Lucero Jauregui conducted an unannounced inspection at the facility above and met with Program Director (P1) Evelyn Vasquez. The purpose of the inspection is to conduct a required annual inspection. The group home has a capacity of 6 ambulatory clients, mixed genders, ages 12-17 years old. This program provides services for private placement clients. The facility is a two story house with four bedrooms, six bathrooms, kitchen, dining room, two living rooms, laundry room, four staff offices, two treatment room, medical room, a gym and recreation room. No room commonly used for other purposes was used as a bedroom, and no bedroom serves as a passageway to another room. There was adequate drawer and closet space for children's belongings. There is sufficient linens, blankets, towels and pillows. All hazardous items have been properly stored and made inaccessible. LPA observed sports equipment/toys/books/games for client's recreation time. Emergency exits were free from obstruction. There is adequate indoor and outdoor activity space. The facility has a basketball and volleyball court. Medications are locked in a closet in the medical room. The facility smoke detectors and carbon monoxide detectors were tested and were observed to be in working order; fire extinguisher is properly charged and serviced. The facility has a fully equipped first aid kit and first aid manual. The facility does not have cameras. The applicants stated there were no weapons in the home. Sharp knives were made inaccessible and stored in a locked container in a locked cabinet. The facility has a pool with a locked self latching gate and the fence is at least five -feet high and meets requirements. The hot water temperature was tested and noted to be at 114 degrees and maintained within the regulation range of 105-120 degrees. Trash cans for storage of solid waste had tight fitting lids. (see continuation form LIC809-C dated 10/26/22) The following required forms were posted in the facility: Personal Rights, Grievance Procedures, Emergency Response, food menu plan and Covid-19 related information. Client and personnel files are available electronically at all times for licensing request or review. LPA's reviewed the physical plant, operations, disaster preparedness, emergency intervention, 6 of 6 staff file reviews, 3 of 3 client file reviews, 3 of 3 staff interviews and 3 of 3 client interviews. Based on record review, the licensee did not comply as 3 out of 3 clients (C1-C3) files did not have the current court order, or written authorization of the child's parent or guardian, for each psychotropic medication which poses a potential health, safety or personal rights risk to persons in care. The facility is being issued a citation in accordance with the Title 22, CCR 84070(b)(12). (See LIC809-D dated 10/26/22 for the cited deficiency.) An exit interview was conducted, and this report, appeal rights and LIC 811 was reviewed with Program Director Evelyn Vasquez and a copy of this report was provided.

met_with: Evelyn Vasquez