raw_content:
Narrative:
As for a client's scheduled appointments, the Upcoming Appointments log does corroborate multiple statements (including those of CRH personnel) that medical or dental appointments either were missed or needed to be rescheduled as a result of CRH not being able to facilitate transportation, and that these instances were due to the unavailability of extra personnel to ensure that the staffing ratio in the dorms were sufficient. Based on interviews and a records reviewed, the preponderance of evidence standard has been met; therefore, the allegation is found to be Substantiated. Interim Licensing Standards Section 87072(c), Personal Rights, Welfare and Institutions Code section 16001.9 22 (a)(22) is being cited on the attached LIC 9099D. The details of a particular incident that was purported to be a result of inadequate supervision were refuted based on an interview. No further corroboration or evidence was found to support that staff did not provide adequate supervision to the minor in question. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated.

Investigation Findings:
13On 11/06/ Licensing Program Analyst (LPA) Chad Cabigon conducted an unannounced inspection of this STRTP (Short Term Residential Therapeutic Program) to deliver the findings of, and close, this complaint investigation. LPA met with Georgeta Muresan, Administrator, and the following report was discussed. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Chad Cabigon LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: CHILDREN'S RECEIVING HOME OF SACRAMENTOFACILITY NUMBER: VISIT DATE: 11/06/2023

met_with: Georgeta Muresan, Administrator


state: CA

facility_name: CHILDREN'S RECEIVING HOME OF SACRAMENTO

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Regarding the allegation that staff inappropriately touched minor in care, C1 provided conflicting statements about how C1 was touched. Two witnesses corroborated that C1 provided conflicting details and has a history of not telling the truth. S1 denied the allegation. All witnesses state that they have not observed inappropriate behavior by S1. Documentation reviewed in the staff file did not contain negative reviews nor information to suggest this staff person employed for 2 years has conducted themselves unprofessionally. Due to conflicting statements made by C1, lack of details obtained, records reviewed, and interviews conducted this allegation can not be substantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted. A copy of all reports and appeal rights were provided and discussed with agency representative.

Investigation Findings:
13Licensing Program Analyst (LPA) Connie Goldie arrived at the facility to conduct an unannounced complaint investigation inspection on 12/13/2023 at 09: AM. LPA Goldie spoke with Georgeta Muresan, Program Administrator to discuss the findings of the complaint investigation and allegation stated above. LPA Goldie informed facility staff this case was investigated by LPA Goldie. The initial 10-day complaint investigation inspection was conducted by LPA Goldie on 09/28/2023. During the inspection, LPA Goldie conducted a record review of staff (S1) file and a client (C1) file and requested the following documentation: staff schedule for 09/16/2023 and 09/17/2023 and week of 10/01/2023-10/07/2023, S1's training documentation, staff and youth roster for dorm C, C1's incident reports, Shift notes and case notes for C September 2023, C1's authorized representative contact information and C1's Needs and Service plan. Thirteen confidential interviews, six staff, six children and one witness, were conducted between 09/28/2023 and 11/29/2023. Continued on LIC9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Connie Goldie LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: CHILDREN'S RECEIVING HOME OF SACRAMENTOFACILITY NUMBER: VISIT DATE: 12/13/2023

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

report_type: Complaint Investigation

met_with: Program Administrator Georgeta Muresan

complaint_status: unsubstantiated


raw_content:
Narrative:
Regarding the allegation that staff do not provide mental health resources to minors in care, though there was a delay in the retrieval of requested documentation due to a change of systems in which records were kept, the facility was eventually able to obtain and provide those records. Subsequently, the review of these records could not definitively determine whether or not mental health services, where appropriate, were sufficiently provided to minors in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is unsubstantiated. The citation issued previously is being dismissed. Exit interview conducted; a copy of this report and of the Appeal Rights are being provided to the facility.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton arrived at the facility on 1/11/2024 at 11:45 and spoke with Glynis Butler-Stone, Chief Executive Officer to discuss the findings of the complaint investigation and allegations stated above. The initial 10-day complaint investigation inspection was conducted by LPA Shelton on 10/11/2023. During the inspection, LPA requested face sheets for all clients in the home, the most current needs and services plans for each of the clients, incident reports for the clients pertaining to Injuries and clients absconding from the facility under the age of 12 for September 2023, until current date. A copy of LIC 500 staff personnel and the current clients' roster. LPA conducted fifteen confidential interviews, seven children, seven staff and authorized representatives for the youths at CRH and the reporting party were conducted between 10/11/2023 and 1/9/2024. Report continued on LIC9099C. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Chad Cabigon LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: CHILDREN'S RECEIVING HOME OF SACRAMENTOFACILITY NUMBER: VISIT DATE: 01/11/2024

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


raw_content:
Narrative:
Regarding the allegation that Staff did not seek medical attention to minor in care. The Department has investigated and found there were conflicting statements made during confidential interviews and records reviewed. The youth did receive medical attention for C2's injured ankle. C2's ankle was wrapped, Iced, and elevated. The clinic staff followed up with C2's care and monitored the injury and pain. C2 stated the pain was better in the ankle and then later said the pain was worse. C2 was taken to Urgent Care, and it was reported to CRH that it was a sprain. There were also conflicting reports on when the incident was reported. Regarding the allegation that staff do not report incidents to CCL or minor's authorized representatives. The Department has investigated and found that the CRH does report incidents to CCL and their authorized representatives. LPA Shelton contacted the authorized representatives and found that they were receiving incident reports, or the incidents were being discussed during a clients CFT Meeting. CCL received a report on all incidents mentioned in the complaint as well as others. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted. A copy of all reports and appeal rights were provided and discussed with the agency representative.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton arrived at the facility on 1/11/2024 at 11:45PM and spoke with Glynis Butler-Stone, Chief Executive Officer, to discuss the findings of the complaint investigation and allegations stated above. The initial 10-day complaint investigation inspection was conducted by LPA Shelton on 10/11/2023. During the inspection, LPA Shelton requested face sheets for all clients in the home, the most current needs and services plans for each of the clients, incident reports for the clients pertaining to Injuries and clients absconding from the facility under the age of 12 for September 2023, until current date and current COVID procedures. A copy of LIC 500 staff personnel and a list of clients currently in the home. LPA conducted fifteen confidential interviews, seven children, seven staff, authorized representative for the youths at CRH and the reporting party were conducted between 10/11/2023 and 1/9/2024. Report continued on UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Mary Shelton LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: CHILDREN'S RECEIVING HOME OF SACRAMENTOFACILITY NUMBER: VISIT DATE: 01/11/2024

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


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
There was substantial corroboration between obtained statements from CRH staff (past and present) and youth alike that staffing has been inadequate and that this has been recurring with some regularity in the preceding months from the start of 2023. According to those interviewed who had direct awareness of the actual staffing ratio at different points throughout the year, the inadequacy includes a number of times when the facility was actually out of ratio, by the numbers. Additionally, there have been times when, while the facility was technically in-ratio, no additional staff were on standby to provide support if a situation arose that would have warranted, or indeed called for, such backup to be mobilized. Based on LPA's observations, conducted interviews, and a records review, the preponderance of evidence standard has been met; therefore, the allegation is found to be Substantiated. Interim Licensing Standards (ILS) 87065.5(b)(1)(C) is being cited on the attached LIC 9099-D. Exit interview conducted; a copy of this report and of the appeal rights are being provided to CRH.

Investigation Findings:
13On 1/12/ Licensing Program Analyst (LPA) Chad Cabigon conducted an unannounced inspection of this STRTP (Short Term Residential Therapeutic Program). The purpose of which was to close the investigation and delivery findings. LPA met with Administrator Georgeta Muresan and the following was discussed: After a file review was done on the facility in question, LPA opened the complaint on 09/08/2023 on site at Children's Receiving Home of Sacramento (CRH) campus-a tour of the interior and exterior areas of the physical plant was provided by Ms. Muresan. A request was made to obtain the log or report of actual hours worked by staff, distinguishing it from a schedule. Interviews were conducted with facility youth and CRH personnel (former and current). Unannounced spot checks were conducted by LPA for a total of five inspections in the ensuing time between the start of the complaint investigation and today. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Chad Cabigon LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: CHILDREN'S RECEIVING HOME OF SACRAMENTOFACILITY NUMBER: VISIT DATE: 01/12/2024

announced_status: Unannounced

met_with: Georgeta Muresan

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
None of the interviewees confirmed the details in the complaint narrative-one of the youth purportedly involved in the alleged incident did not report any incident that matched the description in the report, nor did the youth describe any instances of being hit by any other client in the facility, either by hand or with something thrown at them. Two youth indicated that there is sufficient supervision in the dorm and that staff do attempt to de-escalate potential crisis situations and/or intervene in the event of physical altercations between youth. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated. Exit interview conducted; this report along and a copy of the Appeal Rights are being provided to the facility.

Investigation Findings:
13On 05/30/ Licensing Program Analyst (LPA) Chad Cabigon conducted an unannounced inspection of this STRTP (Short Term Residential Program) to close the complaint investigation. LPA met with Administrator Georgeta Muresan to whom the following findings were delivered: On 02/07/ LPA opened the investigation at the facility during which time a tour of the interior and exterior areas of the Program's physical plant was done and an interview with a client was conducted. Additional interviews were done with facility staff, youth, and county personnel. Records reviewed were incident reports and Needs & Services Plans. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Chad Cabigon LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: CHILDREN'S RECEIVING HOME OF SACRAMENTOFACILITY NUMBER: VISIT DATE: 05/30/2024


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
Five out of the six interviews conducted confirmed a client was not sexually abused by any another client while in care. In addition, LPA Turner was not able to obtain accurate identification of the client who allegedly sexually abused the victim during their time in care, and was not able to obtain exact dates and times of incidents reported. During the investigation LPA Turner was informed that the client in care did not mention any assault taking place within the facility. There are cameras in the common areas to monitor and document any incidents that take place within the dorms. Any assault that could have taken place would have been documented, reviewed, and reported by the facility to Community Care Licensing (CCL). It was confirmed by the client in care that they had a romantic relationship with the alleged abuser yet, did not remember the client's name. LPA Turner was not able to interview the alleged abuser during the investigative process due to lack of identification. Lastly, LPA Turner was provided a client roster for the time between July 2022 and December 2022 and the identity of the alleged abuser in care was not found nor identified. The client mentioned varying names of the alleged abuser that were not found on the client roster. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report and the Appeal Rights were discussed and provided to the licensee.

Investigation Findings:
13On December 19, 2024 at approximately 1: PM, Licensing Program Analyst (LPA) Zaria Turner made an unannounced visit to deliver findings to the above facility and met with Facility Administrator, Georgeta Muresan. Prior to the meeting LPA Cabigon initiated the complaint investigation on October 9, 2024. No deficiencies were cited during that inspection. LPA Turner requested the following documents: SIRs, Needs and Services plan, and IBSP for one client in care, Staff Roster,Staff Schedule,and Client Roster. LPA Turner conducted six interviews between October 31, 2024 and December 12, 2024. Based on evidence obtained and confidential interviews conducted during the investigation process the above allegation cannot be substantiated because there were inconsistent statements throughout the investigation process. Report continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Zaria Turner LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: CHILDREN'S RECEIVING HOME OF SACRAMENTOFACILITY NUMBER: VISIT DATE: 12/19/2024

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

met_with: Georgeta Muresan, Facility Administrator


raw_content:
Narrative:
On the allegation that Staff did not assist minor with obtaining medical care, a digital record of text messaging with CRH on a youth's medical appointment was obtained and reviewed indicating the facility was in receipt of such communication well before the said appointment-this notification contained clear and sufficient information about the appointment. The youth missed the appointment in question as the facility did not properly account for and/or track the appointment. Based on LPA's interviews and a records review, the preponderance of evidence standard has been met; therefore the allegation is found to be Substantiated. California Code of Regulations, Interim Licensing Standards Article 06, Section 97074(c)(1) is being cited on the attached LIC 9099-D. Exit interview conducted; copies of this report and the Appeal Rights are being provided to the facility. On the allegation that Staff did not report incident to responsible party, though the incident in question was confirmed to have happened, there is no explicit requirement for the facility to report that particular type of event; however, the incident was of an unusual circumstance for which the responsible party reasonably expected to receive a report. A Technical Advisory is being issued on this matter. Regarding the allegation that Staff do not communicate with responsible party regarding minor's care, there is no standard of notifying an authorized representative to which the facility can be held regarding certain personal developments a youth experiences. As for the purported change of name in the youth's online medical record, a representative of the child's healthcare group indicated that no individual outside of that dependent's legal guardian(s) can make such a change without either a court order or a Power of Attorney. And with respect to a medication administration issue, though staff did communicate with the responsible party about the matter, further clarification could have been made for the responsible party to better understand what had transpired. A Technical Advisory is also being issued for this matter. Although the allegations mare have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are Unsubstantiated. Exit interview conducted; copies of this report and the Appeal Rights are being provided to the facility.

Investigation Findings:
13On 03/25/ Licensing Program Analyst (LPA) Chad Cabigon conducted an unannounced inspection of this Short-Term Residential Therapeutic Program (STRTP) to close the complaint investigation. LPA was met by Administrator Georgeta Muresan to whom the following findings were delivered: LPA opened the complaint investigation on 12/26/2024 at the facility, during which time a tour of the Children's Receiving Home's (CRH) interior and exterior grounds was done; interviews with facility staff and youth were also conducted. Records reviewed as part of the investigation were the following: a child's Needs & Services Plans, Child and Family Team (CFT) Meeting Notes, medical records including Clinic Progress Notes and an After Visit Summary, admission or services agreement, as well as the facility's relevant Incident Reports, its Policy & Procedure Manual, an Upcoming Appointments log, and correspondences. Additional interviews were conducted with a youth's relative, an outside agency's liaison, and an acute care facility's member services representative. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Chad Cabigon LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: CHILDREN'S RECEIVING HOME OF SACRAMENTOFACILITY NUMBER: VISIT DATE: 03/25/2025


summary: Facility Evaluation

raw_content:
Narrative:
On 5/28/2021 contacted the above facility and spoke with Elisianna Ross, Administrator to follow a incident report that happened on 5/24/2021. LPA requested : pictures of injuries on Foster Youth, video footage of the incident, face sheet, latest needs and services for this youth. LPA requested the following documents from one staff file: ID and training records. Interview with an Administrator was conducted. Additional Interviews will be conducted with Foster Youth and Staff to determine the next steps. A copy if this report was emailed to Elisianna Ross, Administrator.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Elisianna Ross, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 07/16/2021, at approximately PM, Licensing Program Analyst (LPA) Chad Cabigon conducted an on-site case management inspection at this facility. LPA spoke with Administrator Elisianna Rios and Intake Program Coordinator Julie Tibbetts. An incident that took place yesterday, 07/15/2021, was discussed that involved the discovery of contraband on facility grounds and their confiscation from clients' possession. Also discussed, in connection with the aforementioned incident, was the facility's decision to give notice of a plan for an impending discharge of a client who is believed to have distributed the contraband and who had been encouraging other clients to engage in self-harm. The Needs & Services Plans, along with CFT (Child & Family Team) Meeting notes were requested, some of which were obtained on this day, by the LPA. An interview with one client was also conducted. Further investigation is required; no citations were issued as of this time.

met_with: Elisianna Rios


summary: Facility Evaluation

raw_content:
Narrative:
On 08/25/2021, at approximately PM, Licensing Program Analysts (LPA) Chad Cabigon and Yuvicela Diaz conducted an unannounced case management inspection at this facility and met with Administrators Elisianna Rios & Georgeta Muresan. This follow-up was in regards to an Incident Report submitted by the facility on 08/23/2021 concerning an incident on 08/22/2021 involving medication administration. In addition to LPAs discussing the the Incident Report with the Administrators, interviews were conducted with two foster placements from Dorm E. No pattern of medication mismanagement was discovered; the incident in question appears to be an isolated occurrence caused by a rare confluence of circumstances including specific windows of time within which the medications are to be dispensed. This concluded the Case Management Inspection; no citations were issued. A copy of this report is being provided to the facility.

met_with: Georgeta Muresan, Elisianna Rios


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst, Kate Mensah and Licensing Program Analyst, Hugo Licea conducted a Case Management Inspection on November 2, 2021, at 10: AM, based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code Section 1538.7. 7 out of Direct Care Staff and 10 out of 14 youth files as identified on the LIC Confidential Names dated November 2, 2021, were reviewed. 5 out of the Direct Care Staff and 6 out of 14 youth were also interviewed. The Plan of Operation including policies and procedures were reviewed. A copy of this report was discussed and provided to Elisianna Rios and Georgeta Muresan Administrators.

met_with: Elisianna Rios, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On 02/24/2022, starting at around 3: PM, Licensing Program Analyst (LPA) Chad Cabigon conducted an unannounced Required Inspection of this facility. LPA was assisted by Administrators Georgeta Muresan and Elisianna Rios. The interior and exterior areas of the physical plant were toured; preliminary interviews were conducted with Ms. Muresan and Ms. Rios; no clients were interviewed for the day. Additional time is needed to complete this inspection. No citations are issued currently as no deficiencies were observed through today's Physical Environment inspection. A copy of this report is being provided to the facility.

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
On 03/02/2022, starting at approximately AM, Licensing Program Analyst (LPA) Chad Cabigon continued this recurring Required Inspection. LPA was met by Administrators Georgeta Muresan and Elisianna Rios, and was further assisted by Facilities Director Travis Murphy with whom maintenance and upkeep of the buildings and grounds were discussed. The campus-wide alarm system was tested including the carbon monoxide detectors. Access to the facility's gas and water shut-off valves were checked. The maintenance storage sheds were also toured and found to be kept secured--no potentially hazardous items or areas on the premises were observed. Interviews were conducted with four direct-care staff and one youth client. No deficiencies were cited; additional time is needed to complete this inspection. A copy of this report is being provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Jean Stidman on 3/7/22 at 9:30am. During the inspection, LPA Stidman met with Georgeta Muresan and Elisianna Rios, Administrators. LPA reviewed four child's records on site at the facility at 9:30am. LPA reviewed two staff personnel files on site at the facility at 11:30am. LPA interviewed two staff on site at 12:30pm. LPA interviewed three children currently taking psychotropic medication at 3:30pm. LPA conducted exit interview with Georgeta Muresan and Elisianna Rios, Administrators at 5:30pm. LPA provided the Summary Report to Georgeta Muresan and Elisianna Rios, Administrators upon completion.


summary: Facility Evaluation

raw_content:
Narrative:
On 03/07/2022, Licensing Program Analyst (LPA) Chad Cabigon continued this Required Inspection and was assisted by Administrators Georgeta Muresan & Elisianna Rios. LPA toured Dorms F, E, D (Cornell, Spellman, Harvard, respectively) with focus on the water temperature at the faucets and showers of each dorm's restroom. LPA also interviewed one facility youth placement and one direct-care staffer (Residential Counselor). No citations were issued today; more time is needed to complete the this Required Inspection.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Jean Stidman on 3/9/22 at 1:30pm. During the inspection, LPA Stidman met with Georgeta Muresan Administrator. LPA interviewed one child currently taking psychotropic medication at 1:30pm. LPA conducted exit interview with Georgeta Muresan, Administrators at 2:00pm. LPA provided the Summary Report to Georgeta Muresan Administrators upon completion.

met_with: Georgeta Muresan Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 03/16/2022, Licensing Program Analyst (LPA) Chad Cabigon continued this recurring Required Inspection--LPA was assisted by Administrator Georgeta Muresan who helped facilitate interviews with three clients. A tour of the facility's vacant dorm was also conducted--no deficiencies were observed with regards to the physical plant. Client and staff records were reviewed but additional time is needed to complete this inspection. No citations are issued as of this time. A copy of this report is being provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 03/17/ Licensing Program Analyst (LPA) Chad Cabigon continued this Required Inspection on-site and was assisted by Administrators Georgeta Muresan & Elisianna Rios. The review of all client records was completed--the facility is found to be in substantial compliance with Regulations and the Interim Licensing Standards. More time is necessary to complete the review of staff records; LPA to return on 03/18/2022. A copy of this report is being provided to Ms. Muresan.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Chad Cabigon continued and completed this Required Two-Year Inspection on 03/18/2022. LPA met with Administrators Georgeta Muresan and Elisianna Rios who assisted with the inspection. LPA conducted a walk-through of the interior and exterior areas of the campus and found the facility to be in compliance with both Regulations and its Program Statement in regards to staff-client ratios. Five direct-care staffers and five clients were interviewed. Three dorms are currently in use, with each dorm having five rooms, none of which are shared; the bedrooms were equipped with appropriate bedding and sufficient furnishing and storage for clients' personal property. The following items were also checked and found to be present and/or in compliance with Regulations: the posting of the facility license and of the Children's Personal Rights; disinfectants and/or cleaning solutions were kept generally inaccessible from the client population; working telephones were available for each dorm; smoke and carbon monoxide detectors were tested; common rooms or areas were available for activities; the dining areas had sufficient seating, furniture in the communal spaces and in the individual bedrooms were in good repair; all physician-ordered medication were centrally stored and locked; hot water temperatures at faucets and other water-dispensing fixtures were all measured to be between 105-120 degrees F; the toilets, bath and shower fixtures were all in good repair; fire extinguishers were observed to be mounted at appropriate places throughout the facility and tagged with compliant service dates; the facility's motor vehicles servicing client needs were inspected and found to be properly maintained. (, 809-c) Staff files were reviewed and found to contain the following items: verified criminal record clearances; First Aid Certificates; a valid and current Certified Administrator's Certificate; documentation of qualifications for each employee; a record of the required initial and continuing or yearly training hours including modules covering manual restraints or emergency interventions. Client files were reviewed and found to be in compliance regarding the following: the Needs and Services Plans, showing initial and subsequent iterations developed consistent with the frequency set forth by Regulations; filled-in Centrally Stored Medication logs for each client; JV-223's present, where required, in a client's medical chart; and separate Psychotropic Medication logs were in order. Per interviews with clients and staff, the facility implements trauma-informed practices as needed; according to interviewed clients, mental health services are rendered in-facility. The Children's Receiving Home of Sacramento is found to be in substantial compliance with the Interim Licensing Standards and Title Regulations. No citations are being issued as a result of this Required Inspection. An exit interview was conducted with facility administration; a copy of this report is being provided presently.


summary: Facility Evaluation

raw_content:
Narrative:
On 04/15/ Licensing Program Analyst (LPA) Chad Cabigon initiated a Case Management inspection into recent events concerning a recently-admitted 16-year old private placement. LPA met with Administrator Elisianna Rios and the following was discussed: a string of behavioral episodes had occurred on 04/13/2022 during the facility's Easter Egg Hunt held on campus; additional occurrences of a similar nature took place on 04/14/2022 and today, 04/15/2022. According to facility administration, they have voiced concerns about the youth in question partly because the youth's behaviors include instances of repetitive but untriggered, aimless, and/or undirected vocalizations such as, "Don't rape me," or "Don't restrain me," as the youth walks about campus randomly and off-program. Per staff, the youth's family has indicated that these are known behaviors. LPA requested relevant records including, where available, progress notes and intake documentation. LPA to conduct additional interviews with clients and staff at a later time--further investigation is required; no deficiencies were cited as a result of today's inspection.

met_with: Elisianna Rios, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 09/08/ Licensing Program Analyst (LPA) Chad Cabigon arrived onsite at this Short-Term Residential Therapeutic Program (STRTP) to start a case management inspection into circumstances surrounding discrepancies that were found in the count and/or documentation of a medication administration. LPA spoke with Kari Hanson, Clinical Director, and Justin Klyczek, HR Generalist. LPA collected a copy of a Controlled Drug Record form of interest, obtained the contact information for two direct care staffers, and requested documentation of the facility having notified a physician of the discovered discrepancies. LPA also inspected the clinic. No citations are being issued as a result of today's inspection. Further inspection may need to be conducted regarding the matter at hand. A copy of this report is being provided to the facility.

met_with: Kari Hanson, Justin Klyczek


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Manager (LPM) Angela King and Licensing Program Analyst (LPA) Dung Mac conducted a case management inspection on December 8, 2022 at 10: AM based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 8 out of Direct Care Staff and 6 out of 13 youth files were reviewed. 6 out of Direct Care Staff and 5 out of 13 youth were interviewed. (See the Confidential Names List, LIC 811, December 8, 2022). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments and Safety Plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPM King and LPA Mac observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Administrators Georgeta Muresan and Elisianna Rios

met_with: Georgeta Muresan & Elisianna Rios


summary: Facility Evaluation

raw_content:
Narrative:
On 12/28/ Licensing Program Analyst (LPA) Chad Cabigon conducted an onsite inspection at this Short-Term Residential Program and met with Administrator Georgeta Muresan. This inspection is part of the process of changing the facility's licensed capacity from 50 to 16. Currently, Dorms C, D, E, F, and A are in use. Dorm A is being occupied by the clients in Dorm C for the moment because of the heating system being in disrepair in Dorm C--the repair of which is set to be completed by either the end of the day today (12/28/2022) or tomorrow (12/29/2022) according to the facility's Director. In Dorms C, D, E, & F, each of four bedrooms contained one bed with the fifth bedroom in each dorm having no bed. Per Ms. Muresan, the plan moving forward is to utilize at least Dorms C, D, E, & F to house clients in the aforementioned configuration--only four of the five rooms will be used as children's bedrooms--with the fifth room being a space to be utilized by children in some yet to be determined way. Ms. Muresan will get back to this LPA about whether or not Dorm A will be included as a useable dorm for the Program's general population or if it should be designated as an isolation unit to utilize during times when a client or clients contract communicable diseases. No citations are being issued as a result of this inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On 02/21/ Licensing Program Analyst (LPA) Chad Cabigon started this facility's Annual/Required Inspection. LPA was met by Administrator Elisianna Rios who gave a tour of the facility grounds. LPA started records review on two client files; LPA also interviewed one youth. This inspection will be continued at a later time.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Chad Cabigon continued this Annual-Required inspection on 02/22/2023. During the inspection LPA met with and was assisted by Administrator Elisianna Rios. LPA conducted a walk-through of the facility inside and out. Facility staff-client ratio at the time of inspection was 1:2, meeting the Regulation requirements-there are four dorms occupied with each dorm having two clients. Three direct-care staffers and three youths were interviewed. LPA observed four client bedrooms and one bathroom per dorm (each bathroom having two separate shower stalls and two toilet stalls) for a total of 16 client bedrooms matching the facility's current licensed capacity. LPA inspected and/or reviewed the following: LPA observed the proper posting of the facility's license and of the Foster Youth Personal Rights; disinfectants/cleaning solutions were secured and kept inaccessible from clients; the refrigerators' temperatures were at 39 and 38 degrees Fahrenheit, and the walk-in freezer temperature was at 0 degrees Fahrenheit; nonperishable foods were sufficiently in-stock for at least one week, and fresh perishable foods were observed to be on-hand sufficient for at least two days; menus were posted and showed an offering of alternative items; each dorm has at least one working landline telephone that clients reported they could use to make confidential phone calls; there were carbon monoxide detectors in all four dorms which were tested and found to be in good working condition; smoke detectors were also observed in all four dorms; there is a common room available for each dorm; the dining area was observed to have enough seating; the youths' medications were centrally stored, locked and inaccessible to the clients; hot water from taps used by youths were measured to be between 105-120 degrees Fahrenheit; fire extinguishers were placed throughout the facility in appropriate locations and were found to have been inspected within the past year; the toilets, wash basins/sinks, bath and shower fixtures were all in good repair; there was soap and paper towel supplies in the (, 809-C) restrooms; the youth bedrooms contained the required linen and furnishings; and no indication of rat or vermin infestation was detected; the disaster and mass casualty plan was posted and observed to be current; in the file review, staff training documentation was present, as well as verified criminal record clearances; documentation of personnel qualifications' verification was also observed; the Needs and Services Plans for the interviewed clients were found to be current and in compliance; the JV223 documents-where available-were also reviewed; separate Psychotropic Medication Administration Records were found where appropriate; based on client interviews, this facility utilizes trauma-informed practices in providing care and supervision to its youth. No citations are being issued as a result of this inspection; an exit interview was conducted with Ms. Rios and and a copy of this report was provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst, (LPA) Tana Kinder made an unannounced inspection on 4/11/23 for the purpose of conducting a case management related to the incident report provided on 04/08/2023. LPA met with the STRTP Administrator to discuss the investigation and the findings. On 04/08/2023 the Children's Receiving Home submitted an incident report related to client/staff ratio. LPA reviewed staffing documentation from that date, Title 22 regulations and the program statement related to staffing policy. LPA conducted 3 interviews. Based upon the interviews and information reviewed related to the incident report dated 04/08/2023, staff followed the facility protocol and regulations. No deficiencies will be cited. An exit interview was conducted and a copy of the report was provided.

met_with: Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 10/26/ Licensing Program Analyst (LPA) Chad Cabigon conducted an unannounced inspection of this Short Term Residential Therapeutic Program (STRTP), the purpose of which was to conduct a case management inspection regarding reports that medical and/or dental appointments have either not been made or have been missed altogether. LPA met with Glynis Butler Stone, CEO, who facilitated a tour of the interior and exterior grounds of the facility--no physical plant deficiencies were observed. No interviews were conducted as of this time. LPA requested a log of scheduled, confirmed medical and/or dental appointments for the children. Further investigation is required; no citations are being issued at this time.

met_with: Glynis Butler-Stone


summary: Facility Evaluation

raw_content:
Narrative:
On 11/22/ Licensing Program Analyst (LPA) Chad Cabigon conducted an unannounced inspection of this facility and met with Georgeta Muresan, Facility Administrator--the purpose of which was to close a case management inspection that was started on 10/26/2023. The case management inspection was initiated in response to reports that medical and/or dental appointments for a particular youth have either not been made or have been missed altogether. Children's Receiving Home (CRH) personnel were interviewed and pertinent facility records were reviewed as part of the inspection. Attempts by this LPA to contact County personnel were unsuccessful. This report serves to effectively close the case management inspection, as a result of which no citations were issued. A copy of this report is being provided to the facility.

met_with: Administrator Georgeta Muresan


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Chad Cabigon conducted an unannounced case management inspection of this STRTP (Short Term Residential Therapeutic Program). LPA met with Administrator Georgeta Muresan and the following were discussed: -recent medication administration errors. -corrective action plan for the staffer in question including individual hands-on re-training to be given by the facility nurse. -updating of medication administration protocol and the accompanying staff training required to implement the protocol. LPA requested training records from Ms. Muresan. No citations are being issued as of this time as further investigation, discussion, and review of the facility's medication administration protocol is required.


summary: Facility Evaluation

raw_content:
Narrative:
On 01/31/ Licensing Program Analyst (LPA) Chad Cabigon conducted an unannounced inspection of this Short Term Residential Therapeutic Program (STRTP) and met with Administrator Georgeta Muresan. The purpose of the inspection was to deliver amended findings for a complaint investigation report dated 10/25/2024. A copy of this report is being provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Misty Valencia and Lyta Vue on 02/20/2025 at 9:00AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Valencia and Vue met with Georgeta Muresan, Administrator and inspected the facility inside and out. LPAs reviewed 3 of 3 child's records and 4 of 4 staff personnel files on site at the facility. LPA reviewed 3 of 3 child's psychotropic medications and medication records. LPA interviewed 4 of 4 staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 0 of 3 of children currently prescribed psychotropic medication due to not being available. LPA provided business card and asked that the children contact LPA when they are available. LPA provided a copy of this licensing report to Georgeta Muresan, Administrator. No deficiencies are being cited at this time. LPA conducted exit interview with Georgeta Muresan, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 03/13/ Licensing Program Analyst (LPA) Chad Cabigon conducted an unannounced case management inspection of this STRTP (Short Term Residential Therapeutic Program) and was met by Administrator Georgeta Muresan with whom recently reported unusual incidents were discussed that involved allegations by youth against direct-care staff. Video surveillance footage will be reviewed and interviews may be forthcoming. Further investigation is required.


summary: Facility Evaluation

raw_content:
Narrative:
On 07/07/ Licensing Program Analyst (LPA) Chad Cabigon conducted an unannounced inspection of this STRTP (Short Term Residential Therapeutic Program) as a result of the facility changing its capacity from 16 to 8. The facility plans to utilize Dorms C and F moving forward, each having four beds. Currently, due to renovations to the bathrooms, some clients are being temporarily housed in Dorm D. No health & safety concerns were noted, no Buildings & Grounds deficiencies were observed. The updated license is hereby issued for a capacity of 8. A copy of this report is being provided to the facility.

met_with: Aleksei Desantiago, TSCF Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 07/22/ Licensing Program Analyst (LPA) Chad Cabigon conducted an unannounced Annual Inspection of this STRTP (Short Term Residential Program). LPA was met by Administrator Georgeta Muresan who facilitated interviews with staff and a file review. More time is needed to complete the Annual Inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On 07/28/ Licensing Program Analyst (LPA) Chad Cabigon continued the Annual Inspection of this STRTP (Short Term Residential Therapeutic Program). LPA met with Julie Tibbett and Aleksei Desantiago who facilitated the continuation of the records review and interviews with clients. A tour of the physical plant was also conducted. Additional time is needed to complete the inspection. A copy of this report is being provided to the facility.

met_with: Aleksei Desantiago, Julie Tibbett


summary: Facility Evaluation

raw_content:
Narrative:
On 07/29/ Licensing Program Analyst (LPA) Chad Cabigon completed this STRTP's (Short Term Residential Therapeutic Program) Annual/Required Inspection. The findings are as follows: The Children's Receiving Home (CRH) is currently operating two dorms, each of which having four client bedrooms with no youth sharing any rooms. Each client bedroom was furnished with a bed and a mattress, beddings & linens, and sufficient personal storage space all found to be in good condition. Each bedroom also had a working light fixture and a smoke detector that appeared to be in working order. The bathroom facility for each dorm has two shower stalls, two toilets, and multiple sinks or stations for handwashing-the fixtures provided hot water at 105 degrees F. Provisions for basic hygiene supplies were on hand. Food services: a walk-in refrigerator maintained a temperature of 37 degrees F was found to be clean and in working order; a walk-in freezer that maintained a temperature of 0 degrees F was also found to be clean and in good repair. The facility has a walk-in pantry where dried goods were stored. Perishable and non-perishable food items were on hand enough for at least seven days and two days, respectively. No food items were found to be past their expiration date and there were no indications of spoilage; the kitchen and dining areas were found to be clean. Weekly menus were observed to be posted and included alternative menu items. The dorms have working landline telephones for clients' use. Each dorm has centralized air and whose climate was maintained within the required room temperature range. No chemicals and other potentially dangerous liquids were found to be accessible to the youth; the campus has a vast outdoor space and whose passageways were kept unobstructed. LPA found there to be service invoices/receipts maintained for vehicles used to transport clients; vehicle inspection by LPA found no indication of disrepair--hazard/blinker lights, headlights, and brake lights were in working order, and there was no indication of smoking in the vehicle (no cigarette/tobacco smell detected). (, 809-c) Confidential client and staff records were kept secure and were made available for review upon request. Five client files and five staff files were reviewed. LPA also reviewed the minutes kept for board meetings. The facility is accredited by COA (Council on Accreditation) and its current accreditation period is through February 29, 2028. Interviews were also conducted with three clients and four facility staffers as part of this year's inspection. One out of five personnel files did not contain proof of current CPR (cardiopulmonary resuscitation) training. Section 87095.65(d)(6)(A) of the Interim Licensing Standards is being cited on the attached 809-D. Exit interview conducted; a copy of this report, and of the Appeal Rights, is being provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 8/14/2025, Licensing Program Analyst (LPA) Sara Luman-Gonzalez arrived at the above facility for the purpose of conducting a collateral interview. LPA was greeted by Crystal Rosario, Rehab Specialist and granted entry into the facility. LPA requested to speak to Child 1 (C1) that was enrolled at Sprouts within the facility regarding a complaint that is not pertinent to the facility. The C1 had just graduated the program and is no longer at the facility. LPA did speak to one staff member and obtained contact information for another staff member for the investigation. The purpose of this report is to document the LPA's visit to the facility.

met_with: Crystal Rosario, Rehab Specialist


summary: Facility Evaluation

raw_content:
Narrative:
On 10/23/ Licensing Program Analyst (LPA) Chad Cabigon conducted an unannounced inspection of this STRTP (Short Term Residential Therapeutic Program)--the purpose of which was to re-deliver the amended findings for a complaint investigation that was completed on 08/27/2025. A copy of this report is being provided to the facility.

met_with: Georgeta Muresan, Administrator


facility_name: CHILDRENS LEGACY CENTER

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPAs) Lyta Vue and Melinda Pope conducted an announced Pre-licensing inspection on 11/13/23 at 9: AM at the above location, as required for the Short Term Residential Therapeutic Program (STRTP) licensure. LPAs met with Shauna Michaels, Administrator. During the pre-licensing visit, LPAs conducted a Health and Safety inspection using the CARE tool. LPAs observed the facility was clean inside and safe. The outside of the facility is spacious and clean with a picnic bench, lawn chairs and a BBQ grill. LPAs observed that there are two floors to the facility. LPAs observed four client bedrooms, equipped with appropriate furniture, bedding, and supplies for clients. Sufficient storage space for client's personal belongings was observed in each room. The facility is requesting to be licensed for 6 clients. There are 7 hired staff as of now. LPAs observed a medication cabinet and fridge in the staff office, but locked, and accessible only to designated staff. The kitchen area was equipped with an adequate amount of utensils, dining supplies, and cups for clients. No food was observed as there are no clients, and no pending placements at this time. Facility will verify required food on hand at time of client placement. LPAs observed a staff office space that is locked and inaccessible to clients, where client records will be locked in file cabinets. The smoke detectors were tested and found to be functional during the inspection and there were functioning carbon monoxide detectors on each floor of the facility. All smoke detectors and carbon monoxide are connected security system and Administrator will receive any notification if detectors goes off. Three fire extinguishers were present, but are all brand new. Facility will make an appointment with Fire Marshall in January of 2023 for the inspection and it will be done before accepting any clients. A fully equipped first aid kit was in the kitchen area. The Foster Youth Bill of Rights was posted in a conspicuous location. Pre-licensing continued on 809c There are two bathrooms in the facility that are accessible to client use. The water temperature was tested and found to be at DEGREES. The facility is ready for licensure as an STRTP and LPAs recommends that the facility be licensed. A signed copy of this report was provided to Shauna Michaels, Administrator.

visit_type: Prelicensing

met_with: Shauna Michaels, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Lyta Vue conducted an unannounced Post-licensing inspection on 03/25/24 at 12: PM at the above location, as required for the Short Term Residential Therapeutic Program (STRTP) licensure. LPA met with Shauna Michaels, Administrator (AD). During the post-licensing visit, LPA conducted a Health and Safety inspection using the CARE tool. LPA observed the facility was clean inside and safe. The outside of the facility is fenced around the building, and spacious, clean and well maintained for outdoor activities. LPA observed that there are two floors to the facility. LPA observed 4 client bedrooms, equipped with appropriate furniture, bedding, and supplies for clients. Sufficient storage space for client's personal belongings was observed in each room. The facility is licensed for 6 clients and 2 clients are currently in placement. An LIC 500 was received, and the facility has 3 bathrooms, 2 for clients and 1 for staff. The water temperature was tested and found to be within regulatory temperature. Staff to client ratio in the day is 2:1, but 2 additional staff are on duty and the ratio for staff to client at 8: PM to 6: AM is 2:2 and on the weekends are required for 3:2. LPA observed the medications to be stored and locked in the staff office in a locked safe. The kitchen area was equipped with an adequate number of utensils, dining supplies, and cups for clients. There are cleaning supplies and dish soap locked under the kitchen cabinet. LPA observed 3 days of perishable food and 7 days of non-perishable food on site. LPA observed a staff office space that is locked and inaccessible to clients, where client records are locked in a file cabinet in the locked staff office. The facility has a garage set up as a gym and made accessible to clients. The laundry room was well maintained, and all cleaning supplies are locked up in the cabinets. The smoke detectors were working properly and found to be functional during the inspection and there were functioning carbon monoxide detectors on each floor of the facility. Three fire extinguishers were present with a recent inspection date of 11/2023 and will expire on 11/2024. A fully equipped first aid kit was in the kitchen area. Report continued on 809c LPA observed the following items posted: - Personal Rights - Emergency Disaster - Exit signs - Foster Care Bill of Rights - Facility Sketch with emergency exit routes identified LPA did not complete inspection, LPA will return on another day. End of report.

met_with: Shauna Michaels, Administrator (AD)


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Lyta Vue and Misty Valencia arrived unannounced to complete a Post-licensing continuation inspection on 04/23/24 at 9: AM at the above location, as required for the Short Term Residential Therapeutic Program (STRTP) licensure. LPA met with Shauna Michaels, Administrator (AD). This 809 is a continuation of a Post Licensing that was conducted on 03/25/24. Inspection Tool was completed and continued on 809 of 03/25/24. LPAs reviewed 5 staff files and 2 client files. LPAs conducted 4 staff interviews and 1 client interview. This facility meets Interim Licensing Standards mandates and is clean, safe, sanitary and in good repair. LPA recommends the facility obtains permanent license with management approval. A signed copy of this report was provided to Shauna Michaels, Administrator (AD). End of report.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Lyta Vue and Licensing Program Manager (LPM) Hillary Hall arrived announced to the facility on this date for the purpose of a Case Management Inspection following a request on behalf of the facility to discuss future plans for the program. LPA and LPM met with Kimberly Johnson, Chief Executive Officer (CEO), Sarah Peery, Director, Kylie Christopherson, Social Worker, Julie Jones, Executive Manager, and Roseanna Locke, Head of Service. During the meeting, LPA and LPM reviewed updates needed to the Program Statement, reporting requirements for Serious Incident Reports, Harm Reduction policies, and training availability for the facility. LPA and LPM received copies of records for two former youth for further review. Following further review of records, additional follow up may be needed. A signed copy of this LIC 809 was provided to the CEO.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Misty Valencia and Bianca Mendez arrived unannounced for the purpose of a case management inspection, following a record review. As the facility is closed, LPAs met with and discussed the case management with former Lindsey Gunsauls, Asst Director (AD), and Sarah Perry former Director of the facility, at Children's Legacy Center Foster Family Agency, located at Cypress Ave., Redding, which is owned by the same licensee. During a meeting with the Department and the facility (STRTP) on June 26, 2024, a Harm Reduction policy was discussed, with regards to a former client's marijuana usage. Licensing Program Manager (LPM) Hillary Hall requested additional records which were received and reviewed by LPA Wendy Brown and LPM following the meeting client was placed at the facility with a history of substance abuse and unauthorized absences. During the meeting on June 26, 2024, the facility indicated that as a Harm Reduction measure, the facility allowed the client to smoke outside of the facility, as a means to encourage the client to remain on site, and not leave without permission to engage in unsafe behaviors of soliciting illegal substances from strangers in the community. LPM indicated this is not an approved Harm Reduction approach. After the meeting, the facility provided all records regarding the client's substance usage and harm reduction measures. The facility documented multiple incidents where the client left without permission, engaged in aggressive and unsafe behaviors, and used substances on the property and away from the property. Upon review of the records, the Department determined that during the client's two months in placement, there was one incident where the client asked for the client's marijuana which the staff had previously confiscated. The staff provided the client with "scraps" of marijuana which were so small, the client was unable to get them to light. On four occasions, the client smoked marijuana which they had acquired while away from the facility. The staff stayed near where the client was smoking outside of the facility, monitoring the client's safety, and encouraging the client to turn in the contraband. A total of two clients were placed in the facility between March 11, 2024 and May 20, 2024. A subsequent meeting was held with the facility on July 15, 2024 to discuss their future plan, and the facility voluntarily closed on July 19, 2024. No citation was issued at the time of this report as the facility is closed and a Plan of Correction could not be completed. Copy of this LIC 809 case management was provided to AD.

met_with: Lindsey Gunsauls, Assistantt Director (AD)


facility_name: CIRCLE C RANCH INC.

raw_content:
Narrative:
Facility staff failed to ensure resident attends ILP Program. Interviews on 3/4/19 with the client and staff all stated the client has refused to go to the Independent Living Program meetings because he had a job, was busy and did not want to go. Client also stated that his job has ended and he will start going to the classes. Facility staff failed to ensure resident is not using illegal substance. LPA conducted interviews on 3/4/19 with the client, staff and teacher. It was reported that the teacher nor the staff witnessed the client smoking marijuana as he walks through an orchard on his way to school The teacher stated the client smelled like marijuana upon arriving at school but did not witness the client smoking marijuana. although the teacher could not confirm she seen client smoking marijuana in the orchards. Based on interviews with the client, staff, teacher, social worker and director, Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated

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

met_with: Howard Austin Administrator


raw_content:
Narrative:
During an interview with RP, they reported that C1 had disclosed that staff had ransacked clients' bedrooms and stolen allowances. In interviews with clients C1-C5, three clients stated their money had been stolen or was missing. One of these clients stated their wallet went missing at school and then reappeared at the facility a few days later, but the money inside was missing. The second client whose money went missing stated they didn't see who had taken it but just "know" that it's a staff member, although no name was given. The third client stated that their money also went missing and believes it was staff because an X-Box controller had also gone missing. This third client stated they believe it was staff because a client wouldn't steal the controller. However, C1-C5 made consistent statements that staff do not ransack client bedrooms and only does bed checks. Consistent statements were made that bed checks consist of staff checking in to make sure clients were okay, and then leaving without doing much. In interviews with staff members S1, S2, S4, and S5, consistent statements were made that staff do not go into client's bedroom to "ransack" or go through client's belongings, taking their personal belongings. S1 stated that the client(s) who claimed that money had been stolen had then gone Absent Without Leave (AWOL) that evening and returned back with food and candies. S1 stated that when they spoke to the client over the telephone and asked about how client was able to purchase the food and candies if their money/allowance had been stolen, the client didn't answer and instead hung up the phone. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No title 22 regulations were cited during today's inspection. Exit interview conducted and a copy of this report along with appeal rights was left with the Administrator, Raynisha McDonald.

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

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

met_with: Administrator, Raynisha McDonald


raw_content:
Narrative:
LPA's observation, interviews conducted, and records reviewed were consistent that there were occasions that FC1 did not attend medical appointments and court hearings as scheduled. AD's statements corroborated that on one occasion the facility staff did not ensure FC1 attended a court hearing. Medical Documentation provided to the Department was reviewed and is consistent that FC1 did not attend all scheduled medical appointments as required or needed, and the facility was unable to provide documentation regarding proof of medical care FC1 received related to multiple injuries reported by facility staff in statements given. Additionally, while the facility staff obtained a dental appointment for FC1 after an injury, his treatment was not obtained and completed in a timely manner and while in care of the facility. Additionally, there were multiple incidents involving FC1 and/or other clients in care that the Department was not made aware of and/or was not reported to the Department as required per Title 22 and STRTP ILS regulations. Based on LPA observations, documentation reviewed, and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. The facility is being issued two citations for deficiencies related to STRTP ILS Regulations, Personal Rights, section 87072(c) and CRC Title Regulations, section 80075(a). An exit interview was conducted with and a copy of this report and Appeal Rights were provided to Eric Mahan, Facility Manager. LPA's observation, interviews conducted, and records reviewed were inconsistent that the facility did not prevent injury to a youth in care and is not ensuring a safe environment for the youth in care. Based on multiple interview statements, an injury was sustained by FC1 during rough housing with another client in care and in the presence of facility staff. AD stated they needed to cover the fireplace to prevent it from happening again, but there is inconsistent information regarding verbal or other redirection given or not given by staff present during the incident that may have prevented the injury from occurring. Additionally, the facility reported an incident, involving FC1 and Law Enforcement searching the facility for weapons but there were no weapons located. Also, the facility was observed to have property damage, including broken windows. All incidents of property damage have not been reported by facility staff to the Department, and therefore a review of Incident Reports, photographs, visual observations, and statements given by individuals interviews were inconsistent in regard to date(s) when the damage to the windows occurred. Interview statements and subsequent observations showed that repairs to the windows were made by the facility, but in an untimely manner. Based on LPA interviews conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of this report was provided to Eric Mahan, Facility Manager.

Investigation Findings:
13Licensing Program Analyst (LPA) Stephannie Verna conducted an unannounced complaint inspection with the above facility on May 19, 2023 at 11: AM and met with Eric Mahan, Facility Manager. LPA spoke with Raynisha McDonald, Administrator via phone. The purpose of the inspection was to deliver complaint findings for the above allegation(s). On December 21, 2022 at 3: PM Licensing Program Analyst (LPA), Stephannie Verna, initiated the complaint investigation related to the above allegation. LPA conducted an inspection of the facility, and gathered documents related to the complaint. During the course of the investigation, the following documents were gathered and reviewed: Authorization and correspondence regarding licensee's authority to distribute Psychotropic Medication, MARs, Needs and Services Plan, Register of Clients, Staff Schedule and Roster, LIC 602 (7/22) - Physician's Report For Community Care Facilities and medical records, Incident Reports, Law Enforcement Reports, Court Reports, Photographs, Receipts and Invoices for Repairs, and Placement History for one youth. Confidential interviews were conducted with nine individuals during the period of 12/21/2022 to 05/01/2023. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Stephannie Verna LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NO. Cal Cr/res., Natomas Park Dr., Ste Sacramento, CA Facility Name: Circle C Ranch INC.FACILITY NUMBER: VISIT DATE: 05/19/2023

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

met_with: Eric Mahan, Facility Manager


raw_content:
Narrative:
The Department's Audit Section conducted a Solvency Audit pertaining to the allegations: the facility is in financial distress and the Facility Administrator is misusing funds. The audit was finalized on June 07, 2023, by Jacqueline Juarez, Auditor and concluded "Based on the documentation and information provided, the Licensee does not have a sound financial plan as described in Section 80062. As of March 2023 utilities were not being paid timely, and food receipts submitted show amounts spent on food were inadequate to meet the USDA guidelines. During the period of September 2022 multiple loans were taken out, bank statement provided for the same period had a low beginning and negative ending balances, with overdrafts. The audit report also indicated that the licensee is making sufficient income to meet operating expenses and licensee is current with payroll; however, funds are not being managed by the licensee to ensure solvency. Based on the Department's Solvency Audit findings, as well as LPA's observations, interviews conducted, and documentation and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. The licensee is being issued two citations for deficiencies related to CCR Title 22 section 80062(a), Finances; and section 80063(a), Accountability. An exit interview was conducted, a signed copy of this LIC-9099 report, LIC-9099D and the Appeal Rights were provided to the facility. LPA's observation, interviews conducted, and records reviewed were consistent that minors have engaged in physical altercations in the facility, however inconsistent regarding a lack of staff supervision or use of interventions to prevent or stop a physical altercation within the facility. Based on multiple interview statements, when clients display unsafe behaviors, such as verbal or physical aggression, staff redirect clients with verbal cues, offer coping skills, separate clients, and de-escalate unsafe behavior with additional interventions as necessary to ensure the safety of youth in care. Clients receive supportive services within the facility to address the aggressive or unsafe behaviors and youth goals related to decreasing unsafe behaviors are documented on their Needs and Services Plans. During instances of imminent danger to self or others, staff contact Law Enforcement for support and/or utilize physical interventions. Additionally, based on a review of documentation, including Incident Reports, the facility submitted Incident Reports regarding physical altercations of clients in care, as well as Law Enforcement Reports when Law Enforcement was contacted to assist staff in de-escalating clients in a physical altercation with staff or peers. Based on LPA interviews conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of this report was provided to Raynisha McDonald, Licensee.

Investigation Findings:
13Licensing Program Analyst (LPA) Stephannie Verna conducted an unannounced complaint inspection with the above facility on June 28, 2023 and met with LPA Verna met with Joe Marrable, Program Director in-person, and with Licensee, Raynisha McDonald, by phone. The purpose of the inspection was to deliver complaint findings for the above allegation(s). The current census is seven youth in care. On 11/21/22, Licensing Program Analysts (LPAs), Jessica Caplinger and Kim Pawlowicz initiated the complaint investigation and met with Raynisha McDonald, facility licensee. LPA conducted an inspection of the facility, and gathered documents related to the complaint. During the course of the investigation, the following documents were gathered and reviewed: Youth Roster, Staff Roster and Schedule, Receipts, Billing Statements, Loan Documents, LIC Monthly Operating Statement for December 2022, LIC Balance Sheet for December 2022, Allowance Ledgers, Repair Invoices/Receipts, Needs and Services Plans, Meal Menu December 2022, Staff Shift Reports, Law Enforcement Reports and Incident Reports, and the facility Program Statement. Confidential interviews were conducted with eleven individuals and attempted with one individual during the period of 11/21/2022 to 06/23/2023. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Stephannie Verna LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NO. Cal Cr/res., Natomas Park Dr., Ste Sacramento, CA Facility Name: Circle C Ranch INC.FACILITY NUMBER: VISIT DATE: 06/28/2023

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

met_with: Joe Marrable, Program Director


summary: Complaint Investigation - Unsubstantiated - 1 deficiency - 1 allegation

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

Investigation Findings:
13Licensing Program Analyst (LPA) Stephannie Verna conducted an unannounced complaint inspection with the above facility on June 28, 2023 and met with LPA Verna met with Joe Marrable, Program Director in-person, and with Licensee, Raynisha McDonald, by phone. The purpose of the inspection was to deliver complaint findings for the above allegation(s). The current census is seven youth in care. On 12/09/22, Licensing Program Analysts (LPA) Jessica Caplinger initiated the complaint investigation and met with Raynisha McDonald, facility licensee. LPA conducted an inspection of the facility, and gathered documents related to the complaint. During the course of the investigation, the following documents were gathered and reviewed: Youth Roster, Staff Roster, Receipts, Billing Statements, Loan Documents, LIC Monthly Operating Statement for December 2022, LIC Balance Sheet for December 2022, Repair Invoices/Grocery Receipts, Needs and Services Plans, Meal Menu, Staff Shift Reports, Law Enforcement Reports and Incident Reports and facility Program Statement. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Stephannie Verna LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NO. Cal Cr/res., Natomas Park Dr., Ste Sacramento, CA Facility Name: Circle C Ranch INC.FACILITY NUMBER: VISIT DATE: 06/28/2023

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

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


summary: Facility Evaluation - 1 deficiency

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

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

met_with: Angela Duhart, Assistant Administrator


summary: Facility Evaluation

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


summary: Facility Evaluation

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

met_with: Raynisha McDonald, facility licensee


summary: Facility Evaluation

raw_content:
Narrative:
On 3/2/ Licensing Program Analyst (LPA) attempted to conduct an unannounced SB484 psychotropic medication inspection. LPA was unable to complete the inspection. LPA left a copy of this report with Derek Thompson, care provider

met_with: Derek Thompson, care provider


summary: Facility Evaluation

raw_content:
Narrative:
On March 17, 2023 at 01: PM Licensing Program Analyst (LPA) Stephannie Verna and Licensing Program Manager (LPM) Dara Campos arrived unannounced at the facility for the purpose of a case management inspection. A case management inspection was determined to be needed due to LPA Verna being informed by the Administrator on March 16, 2023 of an Incident that occurred the week prior and was not reported to the Department by facility staff. Upon arrival there were two cars in the driveway, LPA knocked several times and no answer. LPA called and texted Administrator Raynisha and she arrived at the facility at 10:45. LPA Verna met with Raynisha McDonald, Administrator. LPA Verna and LPM Campos completed an inspection of the facility with Raynisha McDonald, Administrator. LPA Verna discussed the incident with Raynisha McDonald, Administrator, and gathered further information related to Incident, staff and youth involved. LPA completed 1 interview. Further investigation and review needs to be completed. A signed copy of this LIC-809 was provided to the facility and an exit interview was conducted with Raynisha McDonald, Administrator.

met_with: Raynisha McDonald, Administrator