summary: Complaint Investigation - Substantiated - 1 deficiency - 3 allegations

raw_content:
Narrative:
Based on LPA's observations, interviews conducted, and record reviews, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. Interim Licensing Standards Section 84065.2(b)(5) Personnel Duties are being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of the report and appeal rights were provided to Nilda Hashmi, Assistant Program Manager.

Investigation Findings:
13On October 30, 2022, at 10:25 am, Licensing Program Analyst (LPA) Eduardo Barragan conducted a complaint inspection at McAlister Institute Adolescent Group Home South and met with Nilda Hashmi, Assistant Program Manager. The purpose of the inspection was to deliver the findings for the above complaint allegation. LPA Barragan inspected the group home inside and out on September 30, 2022, and noted no deficiencies. LPA interviewed one of one staff (S1), reviewed staff training, staff rosters and other predominate documents. The Department has investigated the complaint alleging that S1 was not adequately trained. Interviews and record review confirmed that S1 was not adequately trained on care and supervision, due to there not being any sort of documentation that S1 received training on care and supervision. The facilities Human Resource Department confirmed that they did not have any sort of documentation of this as well. In addition, there are corroborating statements regarding the allegation. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Eduardo Barragan LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 2 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY NAME: MCALISTER INSTITUTE ADOLESCENT GROUP HOME SOUTHFACILITY NUMBER: VISIT DATE: 11/30/2022

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 0

Deficiencies:
84065.2: (5) Until they complete the 8 hours of training as required in Section 84065(i)(1), new child care staff hired on or after July 1, 1999 shall perform the duties as defined in Subsections (1) through (4) above while under visual supervision.

met_with: Nilda Hashmi, Assistant Program Manager

title: Personnel Duties (b) Child care staff shall perform the following duties


state: CA

facility_name: MCALISTER INSTITUTE ADOLESCENT GROUP HOME SOUTH

summary: Facility Evaluation

raw_content:
Narrative:
On September 9, 2021 at 11:00 a.m, Licensing Program Analyst (LPA) Marisol Lopez made an unannounced case management inspection to the above facility. LPA met with assistant manager, Toni Boyce. LPA conducted a safety inspection and no deficiencies were observed at that time. An exit interview was conducted and a copy of this signed report was provided to assistant manager, Toni Boyce.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Toni Boyce


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Margaret Lentner conducted a case management inspection on 5/24/2022 at 10:10am 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, 9 out of Direct Care Staff and 5 out of 5 youth files were reviewed. 3 out of Direct Care Staff and 5 out of 5 youth were interviewed. (See the Confidential Names List, LIC 811, dated May 24, 2022). The Plan of Operation including policies and procedures were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth case plans, and crisis intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Margaret Lentner observed documentation of completed training records showing 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 Adrianna Caballero - Program Administrator.


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
On July 06, 2022 at 11: AM, Licensing Program Analyst (LPA) Marisol Lopez conducted an unannounced inspection at the facility above. LPA met with Program Administrator (P1) Adrianna Caballero. The purpose of the inspection is to conduct a required annual inspection. LPA inspected the facility inside and out with facility administrator. There is a capacity for six ambulatory placement and one census placement at time of inspection. LPA inspected the physical plant, operational requirements, disaster preparedness, emergency intervention plan and reviewed one of one client file (C1) (see confidential name list, LIC811, dated 07/06/2022) and two of two staff files (S1-S2). LPA conducted two of two staff interviews (S1-S2) and one of one client interviews (C1). The client and staff files are maintained off-site and readily available. The facility is set up as follows: The bedrooms are located upstairs. Bedroom#1 is set-up for two clients, two twin beds, dresser drawers and closet space. Bedroom#2 is set-up for two clients, two twin beds, dresser drawers and closet space. Bedroom#3 is set-up for two clients, two twin beds, dresser drawers and closet space. The bathroom is located in the hallway and accessible for clients. Medication is kept inside a locked closet in a locked cabinet and centrally stored in the Administrator office. The hot water was measured 115.0 to be within the regulatory requirements. All hazardous items have been properly locked and made inaccessible to clients. Toxic chemicals are locked in a cabinet in the garage. Laundry area is located in the garage and maintained locked. Smoke alarm and Carbon monoxide detector is downstairs next to the kitchen. There are also smoke detectors in each room upstairs and in the hallway. Smoke alarms and carbon Monoxide alarms were checked and operable. There is at least one week supply of nonperishable, snacks, and a 2 day supply of perishable foods. The monthly menu is posted on the refrigerator. The facility has fans throughout the house and maintained at a comfortable temperature. Personal Hygiene, wash clothes and extra towels are available for client use. Kitchen sharp items and knives are kept in the office locked. The facility is maintained clean and there were no exit obstructions or potential hazards. Based on record review, the licensee did not comply as 1 out of 1 client's Needs and Service plan 840682(b) did not identify the childs needs in the following areas: (2) Education and (5) Ability to manage his/her own money, including the maximum amount of money the child shall be permitted to have in his/her possession at one time which poses a potential health, safety or personal rights risk to persons in care. The facility is being issued a citation in accordance with the Title 22, CCR 840682(b) Needs and Service Plan. An exit interview was conducted, and this report, appeal rights and LIC 811 was reviewed with Program Administrator Adrianna Caballero and a copy of this report was provided.

Deficiencies:
84068.2(b): Needs and Services Plan

(b) The needs and services plan shall identify the child's needs in the following areas
40682(b): (2) Education and (5) Ability to manage his/her own money, including the maximum amount of money the child shall be permitted to have in his/her possession at one time which poses a potential health, safety or personal rights risk to persons in care.

met_with: Adrianna Caballero


summary: Facility Evaluation

raw_content:
Narrative:
On August 31, 2022, at 11:20 am, Licensing Program Analyst (LPA) Eduardo Barragan conducted an unannounced case management visit at McAlister Institute Adolescent Group Home South to discuss an incident that occurred on August 29, 2022. LPA Barragan met with Adrianna Caballero, Director. An incident was discussed where three clients assaulted a staff member. (Please see 811 for confidential names list.) The Licensee informed LPA Barragan that nothing like this had occurred before. The Licensee stated that the three clients living in the home never showed any type of physical aggression towards staff. The Licensee stated that the three clients weren't even friends while residing at the facility up until the day before this incident occurred. The Licensee stated that the incident occurred around 9: PM. At the time of the incident there was only the three clients residing in the home and one staff member. The Licensee stated that they were in ratio when the incident occurred, due to them being three clients to one staff during night hours. The Licensee stated that they will provide LPA Barragan with the video of the incident once they obtain access to it. Currently the video is downloading in segments however, their IT is fixing the issue at the moment. LPA Barragan provided his email to the Licensee. LPA Barragan and the Licensee discussed that a safety plan needs to be implemented for staff prior to excepting any new clients. LPA Barragan and the Licensee discussed that this saftey plan would need to elaborate night shift hours as well due to this incident occurring at night. The License stated that they will submit this plan to Community Care Licensing (CCL) by 09/02/2022. There are no deficiencies to be cited on this date. An exit interview was conducted, and a copy of this report was printed and provided to Adrianna Caballero, Director.

met_with: Adrianna Caballero, Director.


summary: Facility Evaluation

raw_content:
Narrative:
On October 13, 2023, at 12:47AM, Licensing Program Analyst (LPA) Carol Anderson arrived at Mc Alister Inc. Administrative Office at N. Johnson Avenue, #111, El Cajon, CA 92020 for the purpose of reviewing staff files. LPA met with CEO Jeanne McAlister and Human Resources Services Director Cindie Torres. LPA reviewed five staff files and they had the necessary forms in file. A review of Guardian on October 13, 2023, indicated that all facility staff associated to the facility had DOJ, FBI and child abuse index check clearances. Due to time constraints this annual inspection will be completed at another date and time. Based on the file reviews this date, there are no deficiencies. An exit interview was conducted, and this report was reviewed with Cindie Torres, Human Resources Service Director and a copy of this report was provided.

visit_type: Annual

met_with: CEO Jeanne McAlister


summary: Facility Evaluation

raw_content:
Narrative:
On October 26, 2023, at 2:00PM, Licensing Program Analyst (LPA) Carol Anderson conducted an unannounced annual continuation inspection of the facility. LPA met with Program Administrator (PA) Adrianna Caballero. LPA inspected the facility inside and out with PA Caballero. There is a capacity for six ambulatory clients and three clients are in placement currently. LPA reviewed status of client records; a current disaster plan; list of facility resident, first aid kit, and there were no exit obstructions or potential hazards. The water temperature read 117. There is a sufficient amount of perishable and nonperishable foods and snacks available. Menu was posted on the refrigerator. Area evaluated were kitchen sharp items and knives are kept in the office. The cleaning supplies and toxic which were stored and locked in the garage. The bedroom had adequate storage for clothing and there is one bed per client. Medications are locked in office in a locked container. Client files are up to update. Smoke alarms were checked and operable. Personal Rights are posted. PA stated that there are no weapons or firearms at facility. The facility has a camera located in the dining area. LPA interviewed two staff and two clients. LPA reviewed three clients' files. All necessary forms were in the file. LPA provided licensee with forms LIC 610C, LIC 308 and LIC 500. License shall provide updated forms within the next 30 days. Based on the file reviews this date, there are no deficiencies during today's inspection. An exit interview was conducted and a copy of this report and was given to PA Caballero.


summary: Facility Evaluation

raw_content:
Narrative:
On December 23, 2024, at 4: PM Licensing Program Analyst (LPA) Jacob Salem met with Phillip Emrhein, Administrator of McAlister Institute Group Home to deliver a case management deficiencies report. According to information obtained during the course of an investigation conducted by Community Care Licensing (CCL), the facility did not report multiple incidents to CCL. Based on confidential interviews and records reviewed, it was revealed that the following incidents were not reported to CCL. During May 2024, multiple clients reported that a staff member was allowing clients to miss planned addiction recovery meetings, providing nicotine vapes to clients, and was not preventing or reporting clients using other substances such as marijuana and Xanax. Based on confidential interviews and records reviewed, the facility is being cited for violation of California Code of Regulations, Title 22, Division 6, Chapter 1, 88361(b)(1)(E) Reporting Requirements. A copy of the report was discussed and provided along with appeal rights to Phillip Emrhein, Administrator.

met_with: Phillip Emrhein, Administrator


facility_name: MCKINLEY

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
On 11/8/24 the Department received a complaint alleging facility staff are not ensuring that client's dental needs are being met; facility staff are discriminating against clients in care and facility staff yell at the clients in care. Based on the information gathered during confidential interviews, facility staff indicated clients are not denied medical attention. Staff indicted client was taken to dentist on October 28, 2024, and has a follow up appointment in November 2024. The facility staff indicated clients are not discriminated against and all clients are treated equally. The facility staff indicated staff does not yell or scream at the clients. Confidential interviews could not corroborate the allegations due to contradicting statements being made during interviews. Clients interviewed indicated staff treats all clients equally and clients are not discriminated against by the staff. Clients indicated staff does not yell or scream at clients. LPA reviewed dental exam forms that indicated client was taken to the dentist on October 28, 2024. The other agency's investigative report indicated facility staff reported that due to client being considered an unaccompanied minor, client has private insurance and is technically not allowed to be seen by a dentist within sixty days of arrival. Client however was able to see a dentist twice within a two-week period. There were no safety threats identified and the child is not in immediate danger of serious harm. Based on the interviews and records reviewed the allegations is/are found unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the allegations. Appeals rights were provided and discussed with the facility representative mentioned above. There were no deficiencies cited.

Investigation Findings:
13On February 24, 2025, at 11: AM Licensing Program Analyst Larry Cabral (LPA) conducted a follow-up inspection for the purpose of providing findings for the above complaint allegations. LPA Cabral met with the facility Assistant Director Nadine Gonzalez. During the investigation, LPA Cabral interviewed one facility staff (S1) and one client (C1) on 11/14/24. LPA interviewed three facility staff (S2, S3, S4) and four clients (C2, C3, C4, C5) 1/17/25 (see Confidential Names Form LIC 811 dated February 24, 2025). LPA reviewed incident reports, dental exam forms, health services report and email to health nurse. LPA reviewed the other agency's investigative report and response notice on 2/6/25. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Larry Cabral 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 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: MCKINLEYFACILITY NUMBER: VISIT DATE: 02/24/2025

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

report_type: Complaint Investigation

met_with: Nadine Gonzalez, Assistant Director

complaint_status: unsubstantiated


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
On 08/14/2024, The Department received a complaint alleging that a staff worker at the facility intentionally showed the client a pornographic image, the client was allegedly propositioned for sex by a staff worker, and the staff worker was observed kissing another client. The reported incidents disclosed were said to have occurred on or about 5/25/2024. The staff worker (S1) identified in the report has denied the allegations. S1 explained that on 5/25/2024, she allowed a client to have access to her personal cellular phone that was being projected on the wall in the cottage dining room so that the client could play games or watch videos. S1 disclosed that she received a multimedia message service (MMS) on her phone that contained an adult content image of two persons engaging in having sex while the client was using her cellular phone, and that is when the client accessed the MMS and briefly displayed the image on the wall for one to two seconds. S1 denied that it was intentional but an accident. S1 denied propositioning the same client who had access to her phone. S1 has denied kissing any clients at the facility. Staff (2-5) denied witnessing S1 engage inappropriately with clients. In confidential interviews with the clients, and facility staff workers, one individual identified as other, including a review of the facility security video could not corroborate the allegations. Based on the information gathered during interviews and documentary evidence, it cannot be determined whether the allegations occurred. Therefore, the above allegations are determined unsubstantiated at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged abuse occurred. The resolution to this complaint was discussed with the facility representative and copies of all licensing reports were provided after the inspection. An exit interview was conducted and the Appeal rights were given and explained. No deficiencies were cited at this time.

Investigation Findings:
13On 08/28/2024 at 11: AM, Licensing Program Analyst (LPA) Joseph Vargas conducted a follow-up inspection for the purpose of providing findings for the above complaint. LPA met with Ms. Marti, Administrator. During the course of the investigation, LPA conducted telephonic interviews and in-person visits with Facility Administrator, one staff, one client on 8/16/2024, one staff, once client on 8/19/2024, two staff's, six clients on 8/20/2024, made multiple attempts, with the last one on 8/27/2024 to contact the Federal Field Specialist (FFS). During the inspection LPA requested for review and obtained copy of the staff and client facility roster reports, special incident reports, and security video footage from the facility as part of my investigation for my review. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Joseph Vargas 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 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: MCKINLEYFACILITY NUMBER: VISIT DATE: 08/30/2024

met_with: Ms. Marti, Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On October 21, 2022, at 9:00AM, Humberto Flores, Licensing Program Analyst (LPA), conducted an announced Pre-Licensing Inspection at McKinley Group Home (GH) and met with Patricia White and Dustin Vander Haar. The purpose of the inspection was stated to the facility representative. LPA Flores conducted a walk-through the facility with Dustin Vander Haar. The GH will use 6 cottages to house all the clients that the Office of Refugee Resettlement (ORR) will place with the GH, once licensed. The cottages are Whittier, Kiwanis, Campbell, Gregory, Bashor, and Wood. LPA Flores observed that the cottages are not ready to receive the children due to upgrades and renovations that are taken place throughout the facility. LPA Flores observed that the music and weight room, that was previously in Cottages Kingsley and Fox, were moved to a different area and they are completed finished and ready for its use. A copy of this report was provided to the facility representative. Exit interview conducted.

visit_type: Prelicensing

met_with: Patricia White, Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On November 03, 2022, at 9:15AM, Humberto Flores, Licensing Program Analyst (LPA), conducted an announced Pre-Licensing Inspection at McKinley Group Home (GH) and met with Dustin Vander Haar. The purpose of the inspection was stated to the facility representative. LPA Flores conducted a walk-through out and inside the facility with Dustin Vander Haar. Cottages Kiwanis and Whittier are ready to house children that the Office of Refugee Resettlement (ORR) will place with the GH under the Unaccompanied Undocumented Minors (UUM) program. Cottages Campbell and Gregory are still under construction with renovations and upgrades pending to be completed, according to the facility representative both cottages will be ready by third week of November 2022. The GH will decrease the capacity of the GH to 40 children that will be housed in the Cottages mentioned above. LPA Flores informed the facility representative that a new LIC200 with a Board resolution is needed to make the change. A copy of this report was provided to the facility representative. Exit interview conducted.

met_with: Dustin Vander Haa, Senior Vice-President


summary: Facility Evaluation

raw_content:
Narrative:
On November 16, 2022, at 9:15AM, Humberto Flores, Licensing Program Analyst (LPA), conducted an announced Pre-Licensing Inspection at McKinley Group Home (GH) and met with Dustin Vander Haar. The purpose of the inspection was stated to the facility representative. LPA Flores conducted a walk-through out and inside Cottages Campbell and Gregory with Dustin Vander Haar. Both Cottages are ready to house children that the Office of Refugee Resettlement (ORR) will place with the GH under the Unaccompanied Undocumented Minors (UUM) program. LPA Flores inspected all the rooms where a total of 20 children will be housed. The smoke detector and carbon monoxide detector where tested and operable. The water temperature was at 107F in Campbell Cottage and at 107F in Gregory Cottage. Cottages Kiwanis and Whittier were inspected on 11/03/2022 and are ready to house the clients from the UUM program. The GH representative stated that the facility is still in the process to obtain a Board Resolution authorizing to reduce the capacity from 60 to 40 children, the resolution will be submitted to Community Care Licensing Division (CCLD) along with an Application for A Community Care Facility LIC200. cont.# LPA Flores informed the GH representative that once the resolution is obtained, a new Fire Clearance request will be sent by CCLD to the local fire authority requesting to conduct an inspection, in order to obtain a Fire Clearance. LPA Flores stated that once the Fire Clearance is obtained, the GH will be ready for licensure. A copy of this report was provided to the facility representative. Exit interview conducted.

met_with: Dustin Vander Haar, Senior Vice-President


summary: Facility Evaluation

raw_content:
Narrative:
On 04/05/2023 at 8: AM Licensing Program Analyst (LPA) Noubar Yerkatyan conducted an announced inspection at McKinley Group Home (GH) and met with facility representatives, Melissa Dalziel and Patricia White. The purpose of the inspection was for the move of clients from one cottage to another. The facility is moving the Short Term Residential Therapeutic Program (STRTP) youth from Cottage Fox and Cottage Kingsley to Cottage Bashor and Cottage Wood. Cottage Fox and Cottage Kingsley will house clients. LPA conducted a walk-through inside and out Cottage Kingsley and Cottage Fox. Cottage Kingsley has 8 bedrooms and 3 bathrooms used for clients. Each bedroom will have a twin size bed, dresser, office table, and locker closet. Cottage Kingsley has a common area with couches, wall mounted TV, dining table, and kitchen appliances. This cottage has rooms designed for staff along with staff restrooms. This cottage also has a locked laundry room which will also be used for client linen, and storage of medication. All staff and storage rooms have a lock. Cottage has (2) camera's facing the common area, (2) camera's facing the hallway, and (2) camera's facing the outside patio. Cottage has (2) fire extinguishers that were last serviced on January 05, 2023. Entering the staff office leads into Cottage Fox. Cottage Fox's layout is parallel and identical to Cottage Kingsley. Cottage Fox has the same number of rooms along with cameras. Cottage Fox has 8 bedrooms and 3 bathrooms used for clients. Each bedroom will have a twin size bed, dresser, office table, and locker closet. Cottage Fox has a common area with couches, wall mounted TV, dining table, and kitchen appliances. This cottage has rooms designed for staff along with staff restrooms. This cottage also has a locked laundry room which will also be used for client linen, and storage of medication. All staff and storage rooms have a lock. Cottage Fox has (2) fire extinguishers that were last serviced on January 05, 2023. The smoke and carbon monoxide detectors for both cottages were tested and operable. Fire alarm for both Cottages were tested and was in working order. The hot water temperature was tested and was in working order. At the time of this inspection the facility was observed to be clean, safe, and in good repair. The facility is increasing their capacity from 40-60. LIC 200 was submitted to CCL. Both Cottages are ready to house clients. A copy of this report was provided to the facility representative. Exit Interview conducted.

met_with: Melissa Dalziel, VP/Administrator & Patricia White, Director


summary: Facility Evaluation

raw_content:
Narrative:
On 04/26/2023 at 9: AM Licensing Program Analyst (LPA) Noubar Yerkatyan conducted an announced inspection at McKinley Group Home (GH) and met with facility representative, Patricia White. The purpose of the inspection was to follow-up from a previous visit done on 04/05/23 in order to make sure facility cottages are appropriately suited for client use. LPA conducted a walk-through inside and out Cottage Fox and Cottage Kingsley. All cottage bedrooms have twin size beds, dressers, office tables, and locker closets displayed. Staff offices are appropriately organized. At the time of this inspection both cottages were observed to be clean, safe, and in good repair. A copy of this report was provided to the facility representative. Exit Interview conducted.

met_with: Patricia White, Director


summary: Facility Evaluation

raw_content:
Narrative:
On November 15th at 8: AM Licensing Program Analyst (LPA) Noubar Yerkatyan conducted an unannounced inspection at the above facility for the purpose of conducting an annual/required inspection. LPA met with facility Administrator, Patricia White. LPA and Ms. White toured the facility. LPA obtained and reviewed the following updated documentation: LIC Personnel and Client Roster, LIC C Emergency Disaster Plan, Board of Directors report, Employee Grievance Policy/ Grievance Procedures, Crisis Prevention Intervention Training's, Emergency Preparedness: Disaster and Mass Casualties Drills, Emergency Evacuation Routes, Facility Monthly Activities Calendar, Emergency Intervention Plan, and Complaint Procedures. Community Care Licensing (CCL) focuses its efforts on three priority areas: prevention, compliance, and enforcement. The facility was in full compliance with 7 applicable areas of the Compliance and Regulatory Enforcement (CARE) tools for Children's Residential Licenses. Annual compliance review consisted of the following domains: Physical plant, operations, disaster preparedness plan, emergency intervention, staffing, and client records. The facility consists of six cottages: Whittier, Kiwanis, Campbell, Gregory, Fox, and Kingsley. Cottage Whittier has 8 bedrooms with 10 beds in total. All bedrooms have a twin-size bed, dresser, office table, and locker closet. Cottage has common area with couches, TV, dining table, and kitchen appliances. Cottage has rooms designed for staff along with staff restrooms. Client restrooms were all in working order. The medications and cleaning solutions were locked inside the cabinets in the cottage laundry rooms. There is perishable food enough for 20 days and non-perishable foods enough for client's consumption for more than 3 weeks. All staff and storage rooms have a lock. Cottage has (2) camera's facing the common area, (2) camera's facing the hallway, and (2) camera's facing the outside patio. Fire extinguishers were in working order. Entering the staff office leads into Cottage Kiwanis. Cottage Kiwanis has 8 bedrooms with 10 beds in total. All bedrooms have a twin-size bed, dresser, office table, and locker closet. Cottage has common area with couches, TV, dining table, and kitchen appliances. Cottage has rooms designed for staff along with staff restrooms. Client restrooms were all in working order. The medications and cleaning solutions were locked inside the cabinets in the cottage laundry rooms. There is perishable food enough for 20 days and non-perishable foods enough for client's consumption for more than 3 weeks. All staff and storage rooms have a lock. Cottage has (2) camera's facing the common area, (2) camera's facing the hallway, and (2) camera's facing the outside patio. Fire extinguishers were in working order. Cottage Campbell has 8 bedrooms with 10 beds in total. All bedrooms have a twin-size bed, dresser, office table, and locker closet. Cottage has common area with couches, TV, dining table, and kitchen appliances. Cottage has rooms designed for staff along with staff restrooms. Client restrooms were all in working order. The medications and cleaning solutions were locked inside the cabinets in the cottage laundry rooms. There is perishable food enough for 20 days and non-perishable foods enough for client's consumption for more than 3 weeks. All staff and storage rooms have a lock. Cottage has (2) camera's facing the common area, (2) camera's facing the hallway, and (2) camera's facing the outside patio. Fire extinguishers were in working order. Entering the staff office leads into Cottage Gregory. Cottage Gregory has 8 bedrooms with 10 beds in total. All bedrooms have a twin-size bed, dresser, office table, and locker closet. Cottage has common area with couches, TV, dining table, and kitchen appliances. Cottage has rooms designed for staff along with staff restrooms. Client restrooms were all in working order. The medications and cleaning solutions were locked inside the cabinets in the cottage laundry rooms. There is perishable food enough for 20 days and non-perishable foods enough for client's consumption for more than 3 weeks. All staff and storage rooms have a lock. Cottage has (2) camera's facing the common area, (2) camera's facing the hallway, and (2) camera's facing the outside patio. Fire extinguishers were in working order. Cottage Fox has 8 bedrooms with 10 beds in total. All bedrooms have a twin-size bed, dresser, office table, and locker closet. Cottage has common area with couches, TV, dining table, and kitchen appliances. Cottage has rooms designed for staff along with staff restrooms. Client restrooms were all in working order. The medications and cleaning solutions were locked inside the cabinets in the cottage laundry rooms. There is perishable food enough for 20 days and non-perishable foods enough for client's consumption for more than 3 weeks. All staff and storage rooms have a lock. Cottage has (2) camera's facing the common area, (2) camera's facing the hallway, and (2) camera's facing the outside patio. Fire extinguishers were in working order. Entering the staff office leads into Cottage Kingsley. Cottage Kingsley has 8 bedrooms with 10 beds in total. All bedrooms have a twin-size bed, dresser, office table, and locker closet. Cottage has common area with couches, TV, dining table, and kitchen appliances. Cottage has rooms designed for staff along with staff restrooms. Client restrooms were all in working order. The medications and cleaning solutions were locked inside the cabinets in the cottage laundry rooms. There is perishable food enough for 20 days and non-perishable foods enough for client's consumption for more than 3 weeks. All staff and storage rooms have a lock. Cottage has (2) camera's facing the common area, (2) camera's facing the hallway, and (2) camera's facing the outside patio. Fire extinguishers were in working order. LPA toured the nursing station and facility cafeteria as well. Nursing station has multiple offices with a treatment room and medication room. Both the treatment and medication rooms contained locked cabinets of medications. Attached to the cafeteria was a large auditorium with tables, chairs, and a stage for entertainment. The smoke and carbon monoxide detectors for all cottages were tested and operable. Alarms for both Cottages were tested and was in working order. All cottage hot water temperatures were tested, and all were in working order. Cottages all have working telephones that are accessible to clients and staff. All passageways and grounds were free of any obstructions. The facility utilizes one Chevy Volt vehicle for transportation. Vehicle is serviced as needed. At the time of this inspection the facility was observed to be clean, safe, and in good repair. Administrator is on site at least 20 hours a week and on-call 24/7. For this review, four (4) clients and seven (7) staff were selected for the sample to assess the level of care and services they receive. LPA also conducted interviews with two staff members and two clients. Client's files were reviewed electronically, while staff files were physically reviewed. An exit interview was conducted. LPA provided the facility representative above a signed copy the LIC 809 and LIC 811 reports. There were no deficiencies cited at the time of this inspection.

met_with: Patricia White, STRTP Administrator; Marissa Marti, Director of UCS Program


summary: Facility Evaluation

raw_content:
Narrative:
On 08/14/2024 at 10: AM Licensing Program Analyst's (LPA's) Noubar Yerkatyan and Olena Maico conducted an announced inspection at McKinley Group Home (GH) and met with facility representative, Nadine Gonzalez, Mckinley Assistant Director. The purpose of the inspection was for a capacity decrease from 60 to 30. LPA's and above representative toured cottage Kingsley, Fox, and Whittier. Cottage Kingsley has 8 bedrooms and 3 bathrooms used for clients. There is a total of 10 beds. Each bedroom has a twin size bed, dresser, and office table. Two rooms have two twin size beds with a dresser, night stand and office table. Cottage Kingsley has a common area with couches, wall mounted TV, dining table, and kitchen appliances. This cottage has rooms designed for staff along with staff restrooms. This cottage also has a locked laundry room which will also be used for client linen, storage of over the counter medication, and cleaning solutions. In one of the staff offices, knives and sharp items are kept locked in a box in the locked cabinet. All staff and storage rooms have a lock. Cottage has (2) camera's facing the common area, (2) camera's facing the hallway, and (2) camera's facing the outside patio. Cottage has (2) fire extinguishers that were last serviced on November 14, 2023. Smoke detector, fire alarm, and water temperatures were checked and all in working order. Entering the staff office leads into Cottage Fox. Cottage Fox's layout is parallel and identical to Cottage Kingsley. Cottage Fox has the same number of rooms along with cameras. Cottage Fox has 8 bedrooms and 3 bathrooms used for clients. There is a total of 10 beds. Each bedroom has a twin size bed, dresser, night stand, and office table. Two rooms have two twin size beds with a dresser, office table, and night stands. Cottage Fox has a common area with couches, wall mounted TV, dining table, and kitchen appliances. This cottage has rooms designed for staff along with staff restrooms. This cottage also has a locked laundry room which will also be used for client linen, and storage of over the counter medication, and cleaning solutions. In one of the staff offices, knives and sharp items are kept locked in a box in the locked cabinet. All staff and storage rooms have a lock. Cottage has (2) camera's facing the common area, (2) camera's facing the hallway, and (2) camera's facing the outside patio. Cottage Fox has (2) fire extinguishers that were last serviced on November 14, 2023. Smoke detector, fire alarm, and water temperatures were checked and all in working order. Cottage Whittier is across from Kingsley and Fox. Cottage Whittier has 8 bedrooms and 1 bathroom used for clients. Bathroom consists of 3 sinks, 1 urinal, 2 bathroom stalls, and 3 shower areas with curtains. Each bedroom has a twin size bed, dresser, office table, and night stand. Cottage Whittier has a common area with couches, wall mounted TV, dining table, and kitchen appliances. This cottage has rooms designed for staff along with staff restrooms. This cottage also has a locked laundry room which will also be used for client linen, storage of over the counter medication, and cleaning solutions. Cottage has (2) camera's facing the common area, (2) camera's facing the hallway, and (2) camera's facing the outside patio. Cottage has (2) fire extinguishers that were last serviced on November 14, 2023. Smoke detector, fire alarm, and water temperatures were checked and all in working order. All three cottages were clean, appropriate, and in working order. LPA informed representative that CCLD has requested a new fire clearance. LPA stated that once the Fire Clearance is obtained, the GH will be ready for licensure. A copy of this report was provided to the facility representative. Exit interview conducted.


summary: Facility Evaluation

raw_content:
Narrative:
On November 06, 2024, at 09:00 a.m., Licensing Program Analysts (LPAs) Christopher J. Williams and LPA Gilbert Gutierrez arrived unannounced at Mckinley Youth Center for the purpose of conducting an Annual/Required inspection. LPAs met with Nadine Gonzalez, Assistant Director. A tour of the facility was conducted, and LPAs reviewed the following domains in the Compliance And Regulation Enforcement (CARE) Tool: Physical Plant, Operational Requirements, Disaster Preparedness, and Core/Therapeutic Services. Physical Plant: The license is posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions are locked in a closet and sharps are locked in the office. Facility has non-perishable foods for at least one week and perishable foods for at least two days. Facility provides at least three (3) meals per day. Medications are centrally stored and locked in cabinets, located in the laundry room of each cottage. All kitchen, food preparation, and storage areas are kept clean and free of rodents and other vermin. Each cottage has one or more carbon monoxide detectors in the facility. Each facility cottage provides basic laundry services for the clients. Room temperatures are maintained at 72 degrees F. The hot water temperature was within the required range of 105 to 120 degrees. All toilets, hand washing and bathing facilities are maintained in safe and sanitary operating condition and meet the requirements. No more than 2 children share a bedroom each cottage. All beds are in good repair; equipped with good springs and a clean mattress; and supplied with pillows which are clean and in good repair. Facility provides age-appropriate clothing items and hygiene products. Overall, facility is clean, safe, sanitary and in good repair. Continue on next page.... Continue.... Disaster Preparedness Plan: Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts disaster drill at least every month for each shift. The drills are documented, and the documentation is maintained in the facility for at least a year. Facility maintains an emergency and disaster plan, register of clients, Needs and Services Plan (If applicable) for each client, medication records, and contact information for each client's responsible party and physician. Operations: Facility maintains a current, written plan of operation that meets licensing standards. Facility maintains a register of clients and the register is available upon request. Facility maintains and implements written complaint procedures, and the procedures are posted in a publicly accessible location in the facility. The board of directors regularly conducts meetings to review and discuss the Group Home operations. Cash resources are kept on the facility premises in a locked and secure location. Core/Therapeutic Services: Facility provides core services and supports to children and unaccompanied - minor dependents as appropriate or necessary that are trauma informed, culturally relevant, age and developmentally appropriate and include the following: Specialty mental health services; transition support services; educational and physical, behavioral, and mental health supports; activities to support children and unaccompanied-minor dependents and services to achieve permanency. An exit interview was conducted by LPA, and a signed copy of this report, LIC809, LIC9102TA, LIC811 (Confidential Names List) were provided to the facility representative.


summary: Facility Evaluation

raw_content:
Narrative:
On November 07, 2024, at 9:48 a.m., Licensing Program Analyst (LPA) Christopher J. Williams arrived unannounced at Mckinley Youth Center Group Home for the purpose of continuing / completing an Annual / Required inspection. LPA met with Marissa Marti, Director of UCS and Nadine Gonzalez, Assistant Director. Client Records: LPA continued the inspection by reviewing five (5) client records and interviewing 2 clients. All client records were available to the licensing agency to inspect, audit and copy upon demand. Client records reviewed included, but not limited to, consent forms, assessment and safety plans, removal/discipline/complaint procedures; medical assessments; safeguards for cash resources, personal property and valuables; education records; personal rights forms; and medication administration records. An exit interview was conducted by LPA, and a signed copy of this report - LIC809, and a LIC811 (Confidential Names List) were provided to the facility representative.

met_with: Marissa Marti, Director of UCS


summary: Facility Evaluation

raw_content:
Narrative:
On November 13, 2025, at 09:04 a.m., Licensing Program Analysts (LPAs) Christopher J. Williams and LPA John Bonilla arrived unannounced at Mckinley Youth Center for the purpose of conducting an Annual/Required inspection. LPAs met with Patricia White, Program Administrator. The facility is currently closed and does not have any clients or staff at the group home. Therefore, no clients or staff were interviewed during the inspection. However, a tour of the facility was conducted, and LPAs reviewed the following domains in the Compliance and Regulation Enforcement (CARE) Tool: Physical Plant, Operational Requirements, Disaster Preparedness, and Core/Therapeutic Services. Physical Plant: The license is posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions are locked in a closet, and sharps are locked in the office. The Facility provided at least three (3) meals per day and snacks. Medications are / were centrally stored and locked in cabinets, located in the laundry room of each cottage. All kitchen, food preparation, and storage areas are kept clean and free of rodents and other vermin. Each cottage has one or more carbon monoxide detectors in the facility. Each facility cottage provides basic laundry services for the clients. Room temperatures are maintained at 72 degrees F. The hot water temperature was within the required range of 105 to 120 degrees. All toilets, hand washing and bathing facilities are maintained in safe and sanitary operating conditions and meet the requirements. No more than 2 children shared a bedroom in each cottage. All beds are in good repair; equipped with good springs and a clean mattress; and supplied with pillows which are clean and in good repair. The Facility provides age-appropriate clothing items and hygiene products. Overall, facility is clean, safe, sanitary and in good repair. ... Continued... Disaster Preparedness Plan: The Facility maintained a current, written disaster and mass casualty plan of action. The Facility conducted disaster drills at least every month for each shift. The drills are documented, and the documentation is maintained in the facility for at least a year. The Facility maintained an emergency and disaster plan, register of clients, Needs and Services Plan (If applicable) for each client, medication records, and contact information for each client's responsible party and physician. Operations: The Facility maintained a current, written plan of operation that meets licensing standards. The Facility maintained a register of clients and the register is available upon request. Facility maintained and implemented written complaint procedures, and the procedures are posted in a publicly accessible location in the facility. The board of directors regularly conducted meetings to review and discuss the Group Home operations. Cash resources were kept on the facility premises in a locked and secure location. Core/Therapeutic Services: The Facility provides core services and supports to children and unaccompanied - minor dependents as appropriate or necessary that are trauma informed, culturally relevant, age and developmentally appropriate and include the following: Medi-Cal specialty mental health services; transition support services; educational and physical, behavioral, and mental health supports; activities to support children and non-minor dependents and services to achieve permanency. An exit interview was conducted, no deficiencies were issued during the inspection, and a signed copy of this report was discussed and provided to the facility representative.

met_with: Patricia White, Program Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 09/01/2023 at 8: AM, Licensing Program Analyst (LPA) Noubar Yerkatyan made an unannounced visit to the above facility for the purpose of a case management inspection. The purpose of the inspection is to follow-up on a Special Incident Report (SIR) received by the Department on 07/28/2023, (see confidential names list). The SIR indicated on 07/28/2023, staff (S1) used inappropriate Spanish to address client (C1). LPA conducted interviews with (1) client and (6) staff. All interviews revealed that S1 used inappropriate Spanish words to address C1 in the cottage. Witnesses were interviewed and all statements were consistent. Facility gave S1 their first written warning and provided training. There is evidence to prove that S1 failed to meet Title Regulations. Therefore, a deficiency is being issued. Appeal Rights were given. A copy of LIC 809, 809-D, and 811 was provided to above facility representative.

met_with: Patricia White, McKinley STRTP Director


summary: Facility Evaluation

raw_content:
Narrative:
On 08/30/2024 at 12: PM, Licensing Program Analyst (LPA) Joseph Louis Vargas conducted an unannounced visit to the above facility for a case management inspection. LPA Vargas met with the Program Director Ms. Marti. The inspection was to follow up on a Special Incident Report (SIR) received by the Department on 08/12/2024 (refer to Confidential Names List dated 08/30/2024). The SIR read that on 05/25/2024, staff (S1) allowed a client (C1) to utilize S1's cellular phone to watch/play a gaming video. The cellular phone was being mirrored, projected to the common area wall near the kitchen and dining area. C1 while in control of S1's cellular phone, a Message Media Service (MMS) was allegedly received. That is when the client opened the MMS application and briefly displayed a photo image of two persons engaging in sex. LPA Vargas obtained and reviewed security video evidence with no audio and supports the incident on 5/25/2024. There were no other clients who saw the image that was being projected on the cottage wall. Staff #1 did not report the incident on 05/25/2024. The Facility Program Director became aware of the incident on 08/12/2024 after a client reported the incident after the fact, which included a review of video footage in the cottage on 5/25/2024. The facility submitted a late Special Incident Report on 08/12/2024. Following a review of the deficiency cited per Title 22, Division 6, Chapter 1, Article 06. Continuing Requirements of the California Code of Regulations, and listed on the LIC 809-D on page 2 of this report, including the Confidential Names List (LIC811) . An exit interview was conducted, and a copy of the reports and the Appeal Rights were provided to the facility representative.

met_with: Ms. Marti, Program Diorector


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Pedro Ramos conducted a follow-up complaint inspection to the above facility for the purpose of delivering findings for the above complaint allegation. During the course of investigating the allegation, LPA conducted interviews with staff and county social worker, (see Confidential Names LIC 811 dated April 16, 2026). Interviews and review of documents revealed the facility staff failed to ensure minor was administered medication. Facility staff/administrator only made one attemp to contact social worker to have documentation properly filled out to provide minor his medication. Failure to receive appropriate documentation contributed to minor being hospitalized. Based on the information obtained, there is a preponderance of the evidence to prove that the facility failed to meet Title 22 regulations. Therefore, the above allegation is substantiated. Deficiencies were cited. Appeal Rights were given. An exit interview was conducted, and a signed copy of this report was left with above staff. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Pedro Ramos 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 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: MCKINLEYFACILITY NUMBER: 197807021

met_with: Patricia White, Administrator

complaint_status: SUBSTANTIATED


facility_name: MICHAEL'S YOUTH TREATMENT HOME FOR BOYS

summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On December 13, 2022 at 8: AM, Licensing Program Analysts (LPA's) Jessica Peete and Sarah Lo conducted an unannounced annual inspection at Michael's Youth Treatment Home for Boys Group Home. LPA's were met at the facility by Facility Manager Gabriela Becerra and Administrator Ruby Barajas. LPA's began a physical plant inspection at 9: AM assisted by the Facility Manager and Administrator.. The facility is two stories; a physical plant inspection was completed and included the following checks: Kitchen, dining room, living room refrigerator/freezers, food storage areas, one staff bathroom, one staff office, two client bathrooms, and three client bedrooms (B1-B3) Bedrooms are arranged so that no more than two clients are in a room, and there is one client per bed. Each client room has the appropriate linens, pillows, comforters, and mattresses are in good repair. Extra linens are stored in the hall closet. Additionally, there is adequate drawer space for each client's belongings. Cleansers, chemicals, and cooking knives are inaccessible to clients. Cleaners and chemicals are locked in the downstairs closet. Cooking knives are in a locked in the staff office. Upon inspection the first aid kit was complete and located in the staff office. Licensee maintains an adequate supply of food and a variety of snacks for clients. LPA observed a minimum seven day non-perishable and a two day perishable supply of food. Additionally, LPA observed the following postings: facility license, grievance procedures, personal rights, Ombudsman poster, visitation policies, and current menu. Age appropriate games and books were observed for client's recreation time. The facility's outside grounds were also inspected and found to be clean, well maintained, and free of observable hazards. There is adequate indoor and outdoor activity space, and all exits were free from obstruction. LPA observed the facility pool, in the backyard, to be inaccessible clients. The fence around the pool has a self-latching gate and measured over five feet tall. The pool is clean and well maintained. (Continued on LIC C ) The facility has an operable carbon monoxide detectors and smoke detectors located throughout the facility. The fire extinguishers were properly charged, serviced, and located in the kitchen and upstairs hallway. Medications were centrally stored locked inside of the staff office. The washer and dryer are located inside the facility, next to the garage, and accessible to clients with staff assistance. Per Facility Manager's statement clients are supervised while they do their own laundry and LPA observed detergents are kept locked. The facility has one vehicle used to transport clients to appointments and recreational activities. The vehicle was observed to be in safe operating condition. At 9: AM, LPA observed, client bathroom one had two sinks. Water in sink one measured 136.2 degrees Fahrenheit and sink two measured 133.7 degrees Fahrenheit. The water in client bathroom two measured 133.5 degrees Fahrenheit. At 9: AM the LPA's observed the trash cans in both client bathrooms were missing lids; this was corrected during the visit. At 10: AM, LPA observed window screens were missing from all three client bedrooms. The licensee was cited for the following deficiencies: Title California Code of Regulations (CCR) 80088(e)(1)... Hot water temperature controls shall be maintained to automatically regulate temperature of hot water ...used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). CCR 80088(f)(1) ...(1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof. CCR 80088(b) All window screens shall be in good repair and be free of insects, dirt and other debris. At 10: AM, assisted by the Facility Manager and Administrator LPA's began review of the Disaster Preparedness, Operational Requirements, Emergency Interventions. At 10: AM, LPA's observed the licensee's disaster plan did not include documentation of quarterly emergency drills, and there were no procedures addressing the storage and preservation of medications. The licensee was cited with the following technical violations of the Health and Safety Code (HSC): HSC 1565(c) A facility shall conduct a drill at least quarterly for each shift... (Continued on LIC C) HSC 1565(a)(7)(E) A facility shall have an emergency and disaster plan that shall include... (7) Procedures that address...(E) Storage and preservation of medications... At 11: AM LPA observed the licensee had not trained staff on emergency interventions. Per Facility Managers statement, staff was last trained in May 2021. The Facility Manager stated a training is scheduled for 12/16/2022. The licensee was cited with the following technical violations: CCR 84365(d) The licensee must maintain a written record of the facility staff training. CCR 84365(d)(1) ... Documentation of training received must be maintained in the personnel record for each staff member... CCR 84365(d)(1)(A) The licensee must maintain a written record of the facility staff training. (1) Documentation of training received must be maintained in the personnel record for each staff member and must include: (A) Dates, hours, and description of the training completed. CCR 84365(d)(1)(B) The licensee must maintain a written record of the facility staff training... (1) Documentation of training received... must include: (B) Name and training certificate of the instructor who provided the training. CCR 84365(d)(1)(C) The licensee must maintain a written record of the facility staff training... (1) Documentation of training received... must include: (C) Certification from the instructor that the staff member has successfully completed the competency test. CCR 84365(e) Facility personnel must receive on-going training to maintain certification (Continued on LIC C) At 12: PM LPA's began the review of five staff files ( S1-S5). The licensee was cited for the following technical violations regarding staff training (CCR) 84065(i)(3)(V) ...new child care staff hired on or after July 1, 1999, shall complete a minimum of 24 hours of initial training comprised of the 8 and 16-hour training... (3) Training shall include, at a minimum, all of the following topics... (V) A child's right to receive sexual and reproductive health care and information. CCR 84065(i)(3)(W ...new child care staff hired on or after July 1, 1999, shall complete a minimum of 24 hours of initial training comprised of the 8 and 16-hour training... (3) Training shall include, at a minimum, all the following topics...(W) A child's right to have their sensitive health information kept confidential. CCR 84065(i)(3)(X) .... new child care staff hired on or after July 1, 1999, shall complete a minimum of 24 hours of initial training comprised of the 8 and 16-hour training... (3) Training shall include, at a minimum, all of the following topics... (X) The duties and responsibilities of the assigned case management worker and the licensee to ensure that children can obtain sexual and reproductive health services and information. CCR 84065(i)(3)(Y)... new child care staff hired on or after July 1, 1999, shall complete a minimum of 24 hours of initial training comprised of the 8 and 16-hour training... (3) Training shall include, at a minimum, all of the following topics... (Y) Guidance about how to engage and talk with children about healthy sexual development and reproductive and sexual health in a manner that is medically accurate, age or developmentally appropriate, trauma informed, and strengths based. CCR 84065(i)(3)(Z) ... new child care staff hired on or after July 1, 1999, shall complete a minimum of 24 hours of initial training comprised of the 8 and 16-hour training... (3) Training shall include, at a minimum, all of the following topics... (Z) Information about current contraception methods and how to select and provide appropriate referral resources and materials for information and service delivery. During the record review LPA observed staff was hired prior to the effective date of the regulation 10-01-2022. However, the licensee has not updated staff training to include the required information as cited above. (Continued on LIC C) At 1: PM LPA observed the licensee could not provide documentation regarding staff training. The following deficiencies were cited: CCR 84065(i)... new child care staff hired on or after July 1, 1999, shall complete a minimum of 24 hours of initial training comprised of the 8 and 16-hour training. CCR 84065(i)(1)(C)(4) Successful completion of job shadowing shall be verified by a statement completed by the experienced facility personnel.... CCR 84065(i)(1)(D) Within 7 calendar days of completion of the 8 hour training, the administrator or administrator's designee shall assess if each child care staff understands and can apply the training. CCR 84065(i)(1)(D)(2) Within 7 calendar days of completion of the 8 hour training, the administrator or administrator's designee shall assess if each child care staff understands and can apply the training. (2) The assessment shall be documented in each child care staff personnel record. CCR 84065(i)(2)... new child care staff hired on or after July 1, 1999, shall complete a minimum of 24 hours of initial training comprised of the 8 and 16-hour training as specified in (1) and (2) below: (2) Sixteen hours of training shall be completed by new child care staff within 90 days of hire. CCR 84065(i)(2)(A)... new child care staff hired on or after July 1, 1999, shall complete a minimum of 24 hours of initial training comprised of the 8 and 16-hour training... (A) New child care staff who work a maximum of 20 hours per week shall complete the additional minimum 16 hours of training within 180 days of hire. CCR 84065(i)(2)(B)... new child care staff hired on or after July 1, 1999, shall complete a minimum of 24 hours of initial training comprised of the 8 and 16-hour training...(B) Within 30 days of completion of the 16 hour training, the administrator or administrator's designee shall assess if each newly hired child care staff understands and can apply the training. CCR 84065(i)(2)(B)(2)... new child care staff hired on or after July 1, 1999, shall complete a minimum of 24 hours of initial training comprised of the 8 and 16-hour training...(B) Within 30 days of completion of the 16 hour training, the administrator or administrator's designee shall assess if each newly hired child care staff understands and can apply the training. (2) The assessment shall be documented in each child care staff personnel record (Continued on LIC C) CCR 84065(j)(1)... all child care staff shall complete a minimum of 20 hours of annual training... CCR 84065(j)(1)(A)... all child care staff shall complete a minimum of 20 hours of annual training...(A) At least 5 hours of the annual training shall consist of course work from an entity other than the group home... CCR 84065(j)(2)... newly hired child care staff, hired on or after July 1, 1999, shall complete a minimum of 16 hours of annual training within the first 12 months of employment, for a total of 40 hours of initial and annual training... CCR 84065(j)(2)(A)... newly hired child care staff, hired on or after July 1, 1999, shall complete a minimum of 16 hours of annual training within the first 12 months of employment, for a total of 40 hours of initial and annual training... (A) At least 4 hours of the annual training shall consist of course work from an entity other than the group home...or other direct training provided by a qualified individual...who is not affiliated with the group home licensee. CCR 84065(j)(4)(A) A portion of this training shall address oversight and monitoring of psychotropic medications for children in foster care and related topics specified in Section 16501.4(d) of the Welfare and Institutions Code. Based on observations, made during the inspection, deficiencies are being cited, see the LIC D. Due to time constraints, LPA will return to complete the inspection at a later date. An exit interview was conducted, and a copy of this report and appeal rights was provided/emailed to Administrator Ruby Barajas.

Deficiencies:
84065(i): Personnel Requirements

(i) Notwithstanding Sections 80065(f)(1) through (6), new child care staff hired on or after July 1, 1999, shall complete a minimum of 24 hours of initial training comprised of the 8 and 16-hour training as specified in (1) and (2) below

met_with: Gabriela Bacerra Facility Manager, Ruby Barajas Program Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On December 15, 2022 at 9: AM, Licensing Program Analysts (LPA's) Jessica Peete and Linda Haynes conducted an unannounced continuation visit at Michael's Youth Treatment Home for Boys Group Home. LPA's were met at the facility by Facility Manager Gabriela Becerra and Administrator Ruby Barajas. LPA Peete visited the facility on 12/13/2022 to complete inspection of the Physical Plant, Disaster Preparedness, Operational Requirements, and Emergency Interventions. At 9: AM assisted by the Facility Manager, LPA began review of three client files (C1-C3) At 10: AM LPA provided the licensee technical assistance in connection with Title California Code of Regulations (CCR) 84077(a)(2) ... Provision of an allowance to all children no less frequently than once per month...Per Facility Manager and Administrator statement. Client's participation in the program is thirty days or less. The licensee was advised that if the clients are in care longer than thirty days; they must be given an allowance. At 10: AM LPA observed the licensee did not have Needs and Services Plans for clients in care. Per Facility Manager and Administrator's statement client's participation in the program is thirty days or less. Licensee was advised that clients in care, longer than thirty days, are required to have a needs and services plan that address their needs as listed below. The licensee was provided with technical assistance in connection with following Title California Code of Regulations (CCR): CCR 84068.2(a)... Social work staff shall obtain the information specified in Section 84070, and shall develop an individual needs and services plan for the child... CCR 84068.2(b) The needs and services plan shall identify the child's needs in the following areas: CCR 84068.2(b)(1) The needs and services plan shall identify the child's needs in the following areas: (1) Reason for placement. (Continued on LIC C) CCR 84068.2(b)(2) The needs and services plan shall identify the child's needs in the following areas: (2) Education. CCR (b) The needs and services plan shall identify the child's needs in the following areas: (2) Education. (A) If the information specified in Section 84070(b)(4) is not available, the plan shall specify a method for determining such needs. CCR 84068.2(b)(5) (b) The needs and services plan shall identify the child's needs in the following areas: (5) Ability to manage his/her own money, including the maximum amount of money the child shall be permitted to have in his/her possession at any one time. CCR 84068.2(c) The needs and services plan shall include the following information regarding services necessary to meet the child's needs: CCR 84068.2(c)(1) The needs and services plan shall include the following information regarding services necessary to meet the child's needs: (1) Types of services necessary. At 11: AM , LPA observed the licensee did not have documentation pertaining to bedroom sharing arrangements, to be maintained in each client rerecord. The licensee was provided with technical assistance in connection with CCR 84087(e) in every situation where children share a bedroom, the licensee shall document that the bedroom sharing arrangement ensures the health and safety of each child and that the children are compatible... This documentation shall be maintained in the child's record. At 11: AM, LPA measured the hot water in both client bathrooms. Bathroom one, sink one, measured 119.4 degrees Fahrenheit. Sink two measured 118.2 degrees Fahrenheit. Bathroom two measured 117.3 degrees Fahrenheit. LPA Haynes conducted two staff interviews and three client interviews. Based on observations, from today's visit, no deficiencies are being cited. An exit interview was conducted and a copy of this report and appeal rights were given to Administrator Ruby Barajas. This is an amended report of a report that was originally issued on 12/15/2022


summary: Facility Evaluation

raw_content:
Narrative:
On 12/ 21/2022 at 8:37 am, Licensing Program Analyst (LPA) Jessica Peete met with Michael's Youth Treatment Home for Boys Group Home (GH) Facility Manager Gabriela Becerrara to amend the LIC 809 created and provided to the GH on 12/15/2022. Exit interview conducted. A copy of this report and the amended report were provided to Facility Manager Gabriela Becerra.

met_with: Facility Manager Gabriela Becerra


summary: Facility Evaluation

raw_content:
Narrative:
On March 18, 2024 at 8: AM, Licensing Program Analyst (LPA) Jose Gonzalez conducted an unannounced annual inspection at Michael's Youth Treatment Home for Boys Group Home. LPA were met at the facility by Facility Manager Gabriela Becerra and Administrator Ruby Barajas. LPA's began a physical plant inspection at 9: AM assisted by the Facility Manager and Administrator.. The facility is two stories; a physical plant inspection was completed and included the following checks: Kitchen, dining room, living room refrigerator/freezers, food storage areas, one staff bathroom, one staff office, two client bathrooms, and three client bedrooms (B1-B3) Bedrooms are arranged so that no more than two clients are in a room, and there is one client per bed. Each client room has the appropriate linens, pillows, comforters, and mattresses are in good repair. Extra linens are stored in the hall closet. Additionally, there is adequate drawer space for each client's belongings. Cleansers, chemicals, and cooking knives are inaccessible to clients. Cleaners and chemicals are locked in the downstairs closet. Cooking knives are in a locked in the staff office. Upon inspection the first aid kit was complete and located in the staff office. Licensee maintains an adequate supply of food and a variety of snacks for clients. LPA observed a minimum seven day non-perishable and a two day perishable supply of food. Additionally, LPA observed the following postings: facility license, grievance procedures, personal rights, Ombudsman poster, visitation policies, and current menu. Age appropriate games and books were observed for client's recreation time. The facility's outside grounds were also inspected and found to be clean, well maintained, and free of observable hazards. There is adequate indoor and outdoor activity space, and all exits were free from obstruction. LPA observed the facility pool, in the backyard, to be inaccessible clients. The fence around the pool has a self-latching gate and measured over five feet tall. The pool is clean and well maintained. *****CONTINUED on LIC C***** The facility has an operable carbon monoxide detectors and smoke detectors located throughout the facility. The fire extinguishers were properly charged, serviced, and located in the kitchen and upstairs hallway. Medications were centrally stored locked inside of the staff office. The washer and dryer are located inside the facility, next to the garage, and accessible to clients with staff assistance. Per Facility Manager's statement clients are supervised while they do their own laundry and LPA observed detergents are kept locked. The facility has one vehicle used to transport clients to appointments and recreational activities. The vehicle was observed to be in safe operating condition. LPA assisted by the Facility Manager began the began the review of the staff files (S1-S3) and two client files (C1-C2). Staff files were complete with all required documents. LPA observed the licensee did not have Needs and Services Plans for clients (C1- C2) in care. Per Facility Manager and Administrator's statement client's participation in the program is thirty days or less. Licensee was advised that clients in care, longer than thirty days, are required to have a needs and services plan that address their needs as listed below. LPA observed the licensee did not have Needs and Services Plans for clients in care. Per Facility Manager and Administrator's statement client's participation in the program is thirty days or less. Licensee was advised that clients in care, longer than thirty days, are required to have a needs and services plan that address their needs as listed below. The licensee was provided with technical assistance in connection with following Title California Code of Regulations (CCR): The licensee was provided with technical assistance in connection with following Title California Code of Regulations (CCR): CCR 84068.2(a)... Social work staff shall obtain the information specified in Section 84070, and shall develop an individual needs and services plan for the child... CCR 84068.2(b) The needs and services plan shall identify the child's needs in the following areas: CCR 84068.2(b)(1) The needs and services plan shall identify the child's needs in the following areas: (1) Reason for placement. (Continued on LIC C) CCR 84068.2(b)(2) The needs and services plan shall identify the child's needs in the following areas: (2) Education. CCR (b) The needs and services plan shall identify the child's needs in the following areas: (2) Education. (A) If the information specified in Section 84070(b)(4) is not available, the plan shall specify a method for determining such needs. CCR 84068.2(b)(5) (b) The needs and services plan shall identify the child's needs in the following areas: (5) Ability to manage his/her own money, including the maximum amount of money the child shall be permitted to have in his/her possession at any one time. CCR 84068.2(c) The needs and services plan shall include the following information regarding services necessary to meet the child's needs: CCR 84068.2(c)(1) The needs and services plan shall include the following information regarding services necessary to meet the child's needs: (1) Types of services necessary. Per Facility Manager and Administrator statement. Client's participation in the program is thirty days or less. The licensee was advised that if the clients are in care longer than thirty days; they must be given an allowance. LPA provided the licensee technical assistance in connection with Title California Code of Regulations (CCR) 84077(a)(2) ... Provision of an allowance to all children no less frequently than once per month...Per Facility Manager and Administrator statement. Client's participation in the program is thirty days or less. The licensee was advised that if the clients are in care longer than thirty days; they must be given an allowance. Based on staff and client file reviews and observations, from today's visit, no deficiencies are being cited. An exit interview was conducted and a copy of this report and appeal rights were given to Administrator Ruby Barajas.


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst Sethany Yem conducted a case management inspection on 5/15/24 at 10:30am 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, 5 out of Direct Care Staff and 5 out of 5 youth files were reviewed. 2 out of Direct Care Staff and 2 out of 5 youth were interviewed. (See the Confidential Names List, LIC 811, 5/15/24). 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 progress notes, 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. LPA Yem observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Administrator Ruby Bajaras.

met_with: Administrator Ruby Bajaras


facility_name: MILBURN HOUSE

raw_content:
Investigation Findings:
13On this date, Licensing Program Analyst (LPA) Leslie Inouye conducted a complaint inspection for the Group Home (GH) for the purpose of delivering the findings for the above complaint allegation. LPA met with Sharde Carter. . During the course of investigating the allegation, LPA conducted interviews with staff members, conducted a record review and obtained information. The information and interviews revealed inconsistencies. Interviews indicate that client arrived at school with abrasions on his upper arm. Witnesses did not feel it was from his seatbelt harness. Staff interviewed and documentation provided did not reveal any issues that would have caused an injury prior to leaveing for school on that day. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the injury was caused by facility staff or an issue of supervision, therefore the above allegation is unsubstantiated UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Les Inouye LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

met_with: Sharde Carter


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13Complaint Specialist C.K. Kinney(CS) Traveled to Hope for Youth Inc offices and met with Vernell Watts to deliver findings of investigation. Investigator Barragan conducted investigation that included review of documentation, review of video evidence, interviews of staff, clients and witnesses and based on the information obtained has determined there is a preponderance of the evidence the allegation occurred. Allegation is Substantiated. This facility is being cited for violation of Health and Safety Code section 1558(a)(2) Conduct Inimical and Title Division Chapter 5 section 84072(d)(14)(a)(2) Personal Rights. Copy of this report, deficiency citations, and LIC Appeal Rights left with Vernell Watts at conclusion of inspection. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Charles Kinney LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, E SHAW AVE FACILITY NAME: MILBURN HOUSEFACILITY NUMBER: 107207169

met_with: Vernell Watts


raw_content:
Investigation Findings:
13On this date, Licensing Program Analyst (LPA) Leslie Inouye conducted a complaint inspection for the Group Home (GH) for the purpose of delivering the findings for the above complaint allegation. LPA met with House Manager Jaquia Wynne. During the course of investigating the allegation, LPA conducted interviews with staff members and clients , conducted a record review and obtained information. The information revealed that Client #1 did sustaine an injury but was inconsistent if it was due to a lack of supervision. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the above allegation occurred due to a lack of supervision, therefore the above allegation is unsubstantiated. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Les Inouye LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

met_with: Jaquia Wynne


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Reyna Martinez conducted a complaint inspection and met with Jaquia Wynne. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the investigation, LPA conducted interviews and reviewed supporting documents provided by the agency. Based on the information obtained during the investigation a preponderance of the evidence that the allegation occurred as reported could not be found. Although the allegation may or may not have happened, or is valid, there is not a preponderance of the evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report and appeal rights were provided at the end of the inspection. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Reyna Martinez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Reyna Martinez conducted a complaint inspection and met with Jaquia Wynne. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the investigation, LPA conducted interviews and reviewed supporting documents provided by the agency. Based on the information obtained during the investigation a preponderance of the evidence that the allegations occurred as reported could not be found. Although the allegations may or may not have happened, or is valid, there is not a preponderance of the evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report and appeal rights were provided at the end of the inspection. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Reyna Martinez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3


summary: Facility Evaluation

raw_content:
Narrative:
On 06/18/2021, Licensing Program Analyst (LPA) Tamara Melikian conducted an annual inspection at the facility. Met at the facility by Program Manager Vernell Watts and House Manager Sharde Carter. Currently there are 4 clients at the facility. Client files and staff files were inspected on this date. Fees checked and the facility is current on all fees. Clients are not home as they are attending school. A physical plant inspection was completed and included the following checks. Facility grounds are clean and free of debris and observable hazard. Adequate indoor and outdoor activity space and materials observed. All facility smoke detectors are in appropriate working order, fire extinguisher is properly charged and serviced. Facility maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted. Medications are locked and centrally stored. Individual beds were observed with appropriate clean linens and are in good repair. Hot water measured 110 degrees. There are no firearms or pets at the facility. There are no bodies of water. Facility appears to be meeting the terms and conditions of their license. There are no deficiencies to be cited on this date. A copy of this report is left at the facility.

met_with: Vernell Watts, Sharde Carter


summary: Facility Evaluation

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Narrative:
On 08/02/2021, an unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian at 2:00PM. During the inspection, LPA met with House Manager Sharde Carter and inspected the facility inside and out. LPA reviewed three children's records and reviewed two staff personnel records for the facility. LPA interviewed one staff at 2:45PM, the Administrator will be interviewed by telephone on this date. One of the children on psychotropic medication was currently not in placement and the other two children are nonverbal and unable to be interviewed. A medication review was conducted at 3:00PM. LPA conducted exit interview with Sharde Carter, House Manager at 3:30PM. There are no deficiencies to be cited on this date.


summary: Facility Evaluation

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Narrative:
On the above date, Licensing Program Analysts (LPAs), Reyna Martinez and Lidia Tinoco traveled to the Hope for Youth main office for the purpose of starting Milburn House annual inspection and met with Clinard Fletcher. 9 records of personnel members were reviewed to ensure staff meet regulatory requirements. All personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. No Deficiencies were cited on today's visit.

met_with: Clinard Fletcher, Administrator


summary: Facility Evaluation

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Narrative:
An unannounced annual inspection was conducted by LPA's (Licensing Program Analyst's) Reyna Martinez and Lidia Tinoco. LPA's met with Jaquia Wynne, House Manager and inspected the facility, inside and out. Centrally stored medications are maintained in a locked closet in a locked cabinet. Sharps and Toxic chemicals are kept locked. The facility has a written emergency disaster plan. All facility smoke detectors were tested and appear to be in appropriate working order, fire extinguisher is properly charged and was last serviced August 2022 . Individual beds were observed with appropriate clean linens and are in good repair. There is at least one-week supply of nonperishable and a two-day supply of perishable foods. The facility is maintained at 75 degrees. Hot water temperature measures 120.4 degrees. Facility has cameras in common areas of the facility. No firearms or weapons are allowed in the facility. No pools. Appropriate staff/client ratios were verified during this inspection. The facility employs 1 facility manager and 7 direct care staff and 1 behavior specialist. 1 staff was available to be interviewed. No clients available to be interviewed. 4 records of clients were reviewed.

met_with: Jaquia Wynne, House Manager


summary: Facility Evaluation

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Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian on 11/02/2022 at 8:45AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Melikian met with Jaquia Wynne, House Manager and inspected the facility inside and out. LPA reviewed 3 children's records and 2 staff personnel files on site at the facility. LPA reviewed 3 children's psychotropic medications and medication records. LPA interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA did not interview any children currently prescribed psychotropic medication on this date as child #1 (see LIC811 dated 11/02/2022) was at school and child #2 and #3 (see LIC811 dated 11/02/2022) are nonverbal. LPA provided a copy of this licensing report to Jaquia Wynne, House Manager. No deficiencies are being cited at this time. LPA conducted exit interview with Jaquia Wynne, House Manager. LPA Tamara Melikian was unable to complete the psychotropic medication on this date inspection as child #1 was at school and unable to be interviewed and will conduct another inspection or interview child #1 at school.


summary: Facility Evaluation

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Narrative:
Licensing Program Corina Carrillo conducted a case management inspection March 14, 2023 at 3:00PM 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, 5 out of Direct Care Staff and 4 out of 4 youth files were reviewed. 2 out of Direct Care Staff and 1 out of 4 youth were interviewed. (See the Confidential Names List, LIC 811, March 14, 2023.) The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth case plans, quarterly assessments, and crisis intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Carrillo 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 Jaquia Wynn.

met_with: Jaquia Wynn


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by LPA (Licensing Program Analyst) Reyna Martinez. LPA met with Jaquia Wynne, House Manager and inspected the facility, inside and out. Centrally stored medications are maintained in a locked closet in a locked cabinet. Sharps and Toxic chemicals are kept locked. The facility has a written emergency disaster plan. All facility smoke detectors were tested and appear to be in appropriate working order, fire extinguisher is properly charged and was last serviced August 2022. Individual beds were observed with appropriate clean linens and are in good repair. There is at least one-week supply of nonperishable and a two-day supply of perishable foods. The facility is maintained at 76 degrees. Hot water temperature measures 118 degrees. Facility has cameras in common areas of the facility. No firearms or weapons are allowed in the facility. No pools. Appropriate staff/client ratios were verified during this inspection. The facility employs 1 facility manager and 8 direct care staff and 1 behavior specialist. 1 staff was available to be interviewed. No clients available to be interviewed. Clients in the facility are all intellectually disabled and non-verbal. Staff files were reviewed and meet all regulatory requirements. 4 records of clients were reviewed. No Deficiencies were cited on today's visit. A copy of this report was left at the facility.


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
An unannounced annual inspection was conducted by LPA (Licensing Program Analyst) Reyna Martinez. LPA met with Jaquia Wynne, House Manager and inspected the facility, inside and out. Centrally stored medications are maintained in a locked closet in a locked cabinet. Sharps and Toxic chemicals are kept locked. The facility has a written emergency disaster plan. All facility smoke detectors were tested and appear to be in appropriate working order, fire extinguisher is properly charged and was last serviced August 2023. Individual beds were observed with appropriate clean linens and are in good repair. There is at least one-week supply of nonperishable and a two-day supply of perishable foods. The facility is maintained at 73 degrees. Hot water temperature measures 107 degrees. Facility has cameras in common areas of the facility. No firearms or weapons are allowed in the facility. No pools. Appropriate staff/client ratios were verified during this inspection. The facility employs 1 house manager and 6 direct care staff and 1 behavior specialist. 1 staff was available to be interviewed. No clients available to be interviewed. Clients in the facility are all intellectually disabled and two non-verbal. Staff files were reviewed and meet all regulatory requirements. 4 records of clients were reviewed. Four deficiencies were cited on today's visit on the attached LIC809-D Page. A copy of this report and appeal rights was left at the facility.

Deficiencies:
80087(a): Deficient Practice Statement
1
2
3
4Based on observation, the licensee did not comply with the section cited above in
80026(h): Safeguards for Cash Resources, Personal Property, and Valuables

(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following

title:
Buildings and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Les Inouye conducted an unannounced Case Management inspection to the Group Home (GH) and met with . Based on interviews conducted and documentation provided it has been determined Milburn House has failed to provide an Incident Report for an injury a client sustained while in care. Based on the LPA's observations, interviews and records review which were conducted, there is a preponderance of evidence to substantiate a violation of regulation based on Title 22, Division 6, Chapter 5 and are being cited on the attached LIC 9099D A copy of the report and Appeal Rights was provided to the FFA.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian on November 7, 2023 at 9:30AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPA Melikian met with House Manager Jaquia Wynne and Program Director Vernell Watts and inspected the facility inside and out. LPA reviewed 3 child's records and 2 staff personnel files on site at the facility. LPA reviewed 3 child's psychotropic medications and medication records at the facility. LPA interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 0 children on site. Two of the children are nonverbal and the third child is at school at this time and will be interviewed at a later time. LPA provided a copy of the licensing report to House Manager, Jaquia Wynne. Deficiency on the attached page. LPA conducted exit interview with Jaquia Wynne, House Manager and Vernell Watts, Program Director.

met_with: Vernell Watts, Jaquia Wynne