raw_content:
Narrative:
During confidential interviews, it was confirmed that S2 did lock C1 in the room for more than thirty minutes without anyone taking over his 1:1. C1 was locked in his room without having anyone near his door to ensure that he was safe. While discussing the allegation with Administrator, Benjamin Rimorin, he stated that due to the most recent behaviors from C2 towards C1, it was discussed and decided between the Licensee, Fenina Pham, Administrator Benjamin Rimorin and the Behavioral Specialist, Haley Garr, that in order to provide extra protection for C1, it would be approved to lock C1 in his room to add an extra barrier between C1 and C2. The condition of this was that staff are to still sit in the hallway to be close to C1 and if for any reason the assigned staff needed to leave their position at any time, they are to notify the lead on shift, and provide the key to C1's door and then the lead is to take over that staff's 1:1 until they return. Seven out of eight confidential interviews confirmed that it is allowed to lock C1 in his room. The Department has investigated the complaint alleging staff locked minor in the room for an extended period of time and staff did not provide adequate supervision to minor. Based on LPAs interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter1, are being cited on the attached LIC 9099D. An exit interview and appeal rights were discussed with Margarita Hernandez, Lead and a copy of this report was provided.

Investigation Findings:
13On May 7, 2025, at 11: AM, Licensing Program Analyst (LPA) Michelle Silvas arrived at Polaris Homes to deliver the findings of the allegations listed above. LPA met with Margarita Hernandez, Lead, who assisted with today's inspection. LPA conducted a walk through of the facility inside and out. Three staff are present and no clients are present. LPA conducted the initial 10-day complaint investigation at the facility on April 17, 2025. LPA conducted eight confidential interviews between 4/17/25 - 5/2/25. It was alleged that on April 14, 2025, S2 needed to make an important phone call so they called S8 to ask if they could lock C1 in the room so they can make their call. S8 said yes that would be fine but be sure to let the lead know. S2 states he let S3 know he was locking C1's door because he needed to step away and that C1 was asleep. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Michelle Silvas LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: POLARIS HOMEFACILITY NUMBER: VISIT DATE: 05/07/2025

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

met_with: Margarita Hernandez, Lead


state: CA

facility_name: POLARIS HOME

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview and appeal rights were discussed. A copy of this report along with the appeal rights were given to Margarita Hernandez, Lead.

Investigation Findings:
13On May 7, 2025, at 11: AM, Licensing Program Analyst (LPA) Michelle Silvas arrived at Polaris Homes to deliver the findings of the allegation listed above. LPA met with Margarita Hernandez, Lead who assisted with today's inspection. LPA conducted a walkthrough of the facility inside and out. Three staff are present and no cients are present. LPA conducted the initial 10-day complaint investigation at the facility on March 03, 2025. LPA conducted six confidential interviews between 3/03/25 - 5/2/25. It was alleged that a third party observed a woman yelling at a minor to "go to your room." LPA conducted seven confidential interviews. Five out of Seven confidential interviews stated that they have not observed any staff yelling at clients. Two out of Seven confidential interviews state that staff do talk in a firm tone, which may appear to those outside of the facility that staff are yelling at clients. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Michelle Silvas LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: POLARIS HOMEFACILITY NUMBER: VISIT DATE: 05/07/2025

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

report_type: Complaint Investigation

complaint_status: unsubstantiated


raw_content:
Narrative:
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview and appeal rights were discussed. A copy of this report along with the appeal rights were given to Benjamin Rimorin, Administrator.

Investigation Findings:
13On May 16, 2025, at 09: AM, Licensing Program Analyst (LPA) Michelle Silvas arrived at Polaris Homes to deliver the findings of the allegations listed above. LPA met with Benjamin Rimorin, Administrator, who assisted with today's inspection. LPA conducted a walkthrough of the facility inside and out. 6 staff and 0 clients are present. LPA conducted the initial 10-day complaint investigation at the facility on April 22, 2025. LPA conducted eight confidential interviews between 4/22/25 - 5/7/25. It was alleged that S1 punched C1 in the head. It was also alleged that clients are not accorded dignity in their relationships with staff. Eight out of eight confidential interviews stated that they have never seen S1 punch C1 in the head. Eight out of eight confidential interviews did not indicate that clients are not accorded dignity in their relationships with staff. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Michelle Silvas LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: POLARIS HOMEFACILITY NUMBER: VISIT DATE: 05/16/2025

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

met_with: Benjamin Rimorin, Administrator


raw_content:
Narrative:
LPA reviewed the video footage of the incident and observed C1 going towards C2s bedroom which is out of the cameras sight. Shortly after, you see C1 pulling C2 on the ground by his left arm and pulls him into his room. During confidential interviews, four out of six interviews stated that they were short staffed on February 22, 2025, which is why no one was sitting outside of C2s room. S1, S2 and S3 who were present at the time of the incident, all stated that they did not see or hear anything. The Department has investigated the complaint alleging Staff did not prevent minor in care from engaging in inappropriate interactions with other minor in care. Based on LPAs interviews which were conducted, review of video footage and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter5, are being cited on the attached LIC 9099D. An exit interview and appeal rights were discussed with Benjamin Rimorin, Administrator and a copy of this report along with the appeal rights were provided. Polaris has worked on preventing C1 from gaining access to C2 by making sure that C2 is never left alone and if he is in his room, staff are always sitting right outside his door. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview and appeal rights were discussed with Benjamin Rimorin, Administrator. A copy of this report along with the appeal rights were given to name and title.

Investigation Findings:
13On 5/23/2025 at 09: AM, Licensing Program Analyst (LPA) Michelle Silvas initiated an unannounced complaint investigation inspection at the above listed facility. LPA met with Benjamin Rimorin, Administrator, who assisted with the inspection. The purpose of the inspection was to deliver findings for the above listed allegation. Six staff and no clients are present. On May 2, 2025, the Department received a complaint regarding this incident. LPA conducted the initial 10-day complaint investigation at the facility on May 7, 2025. LPA conducted six confidential interviews between 4/22/25 - 5/19/25. It was alleged that staff did not prevent minor in care from engaging in inappropriate interactions with other minor in care. It was reported that on February 22, 2025, at approximately 8:00AM, C2, who is non-ambulatory, was in his room sleeping while his 1:1, S1 was in the kitchen preparing C2s breakfast. C1 was in the living room watching TV with his 1:1, S3. C1 left to go towards his room and his 1:1 did not follow him. Around 8:23AM, C2s 1:1, S1, went to his room and noticed that he was not in his room. S1 found C2 in the bedroom of C1 propped up in an upright position on C1s bed. S1 then assisted C2 back to his room. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Michelle Silvas LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: POLARIS HOMEFACILITY NUMBER: VISIT DATE: 05/23/2025

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


raw_content:
Narrative:
The requesting agency requested these documents via email to multiple pertinent individuals on 6/13/2025, 6/18/2025, 6/26/2025, and 7/2/2025. When LPA Burgess conducted an inspection at the agency on 7/24/2025, during an interview with the Administrator, LPA found it to be true that they had not sent the required documents. LPA instructed the Administrator to send the requested portability documents to the worker by COB that day, cc'ing LPA, to which the Administrator agreed. However, on 7/24/2025 the Administrator had only sent the completed RFA10 form as required and did not send the rest of the documents. On 7/25/2025, the Administrator informed LPA that per the CEO, they do not send any information from the Resource Families' file to the subsequent agency. LPA informed the CEO and Administrator of the regulation section which states they must do so, and to comply with the regulation. Administrator and CEO did so, and the documents were sent to the requesting agency as required that day. Concerning the allegation regarding agency staff's conduct being inimical, affecting youth and Resource Parents of the agency, it was alleged by three social workers for youth in care that the Administrator was instructed to remove the youth from the home per direction from Community Care Licensing (CCL) staff which was an inaccurate statement. The Agency Social Worker (AWS) went to the Resource Family Home (RFH) with three other resource parents in an attempt to remove the children. While the children refused to comply with the directive to leave the RFH, the ASW did tell the Resource Parent (RP) they would "let the police know" and left the home. Discussion about this with CSWs indicated that they were informed that CCL was mandating the youth be removed and the FFA refused to discuss alternatives to preserve the placements of the children in RFH. CCL does not intervene in placements, nor would CCL mandate the removal of youth from placement. Confidential interviews indicated that the attempt to remove the youth in care may have been in retaliation for the RP intending to change agencies, taking the placements with them to the new agency. During the investigation, LPA Burgess was informed by another RFH that the Chief Executive Officer (CEO) threatened to rescind their RFH approval for reporting a complaint to CCL. It was also reported that the CEO yelled at RPs. During an interview with the CEO, it was confirmed that the CEO did threaten to rescind the RFH and that CEO yelled at Resource Parent, but that Resource Parent was also yelling. Based on LPA's observations and conducted interviews, the preponderance of the evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. The FFA was cited for violation of the Foster Family Agency Interim Licensing Standards section 88336(f)(1) Application for Resource Family Approval: Portability as the current FFA did not complete the required documentation within 20 business days of the receipt of the application to port to another agency. The agency was also cited for violation of the Foster Family Agency Interim Licensing Standards section 88222(d) Plan of Operation as the agency did not follow their Plan of Operation as outlined in their job descriptions for the Administrator and CEO including the requirement to "demonstrate a cooperative, positive and enthusiastic attitude toward fellow employees, children and families" and "listens to others while suspending judgment; is able to communicate in a respectful and meaningful way while in or out of the office". The job description for the CEO includes a clause regarding conduct, including the responsibility to conduct "one's self in a manner consistent with the agency's code of ethics and code of conduct. Shows professionalism" which was not being adhered to when arguing or yelling at Resource Parent(s). An exit interview was conducted and a copy of all documents were provided.

Investigation Findings:
13On September 5, 2025, at 00:00AM, Licensing Program Analyst (LPA) Michelle Silvas conducted an unannounced complaint investigation inspection at the above listed facility. LPA met with Margarita Hernandez, Lead who assisted with the inspection. The purpose of the inspection was to deliver findings for the above-mentioned allegations. 4 staff and 0 clients are present. LPA conducted the initial 10-day complaint investigation at the facility on July 9, 2025. LPA conducted four confidential interviews between 7/9/25 - 9/26/25. It was alleged that lack of supervision resulted in client injuries and failure to ensure proper treatment for injuries. On June 29, 2025, at approximately 10:30am, S1 and S2 took C1 to the park. S1 walked C1 to the slide and S2 waited at the bottom of the slide. S1 sat C1 down on the slide and let them go while S2 waited at the bottom of the slide to catch C1. This is a known activity that C1 enjoys doing at the park. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Jensen-Hill LICENSING EVALUATOR NAME: Michelle Silvas LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: POLARIS HOMEFACILITY NUMBER: VISIT DATE: 09/05/2025

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


raw_content:
Narrative:
While staff were aware of one of the clients having an allergy to shrimp, they were not sure about the ability to cross contaminate food items using the air fryer until advised by North Bay Regional Center (NBRC) during training provided on July 10, 2025. While it was advised that this could lead to cross-contamination of food items, staff had not observed any new allergic reactions displayed by client in care. The facility purchased another air fryer to cook non seafood items as an extra layer of precaution. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was provided.

Investigation Findings:
13On September 19, 2025, at 10:40AM, Licensing Program Analyst (LPA) Michelle Silvas conducted an unannounced complaint investigation inspection at the above listed facility. LPA met with Margarita Hernandez, Lead. The purpose of the inspection was to deliver findings for the above-mentioned allegation. 5 staff and 2 clients were present during this inspection. LPA conducted the initial 10-day complaint investigation at the facility on July 23, 2025. LPA conducted four confidential interviews between 7/23/25 - 8/15/25. The allegation that staff exposed a client to an allergy-causing food item known to trigger reactions is related to the facility staff preparing clients' foods in the same air fryer, knowing that one of the clients may have been allergic to one of the foods prepared. During interviews, it was discussed that staff had been using the same air fryer to cook shrimp egg rolls and chicken nuggets for each of the clients in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Jensen-Hill LICENSING EVALUATOR NAME: Michelle Silvas LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: POLARIS HOMEFACILITY NUMBER: VISIT DATE: 09/19/2025

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


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Shoua Xiong conducted an unannounced Case Management inspection to the facility on 3/23/21 beginning at 1:15PM. Due to COVID- Restrictions, LPA conduced this Case Management telephonically. LPA spoke with the Administrator, Fenina Pham, and explained that the purpose of today's call was to discuss an Incident Report dated for 3/12/21 which the Department Received on 3/22/21. This Incident Report involved Client (C1) who was placed in a restraint. On today's date, LPA interviewed the Administrator regarding the incident. LPA and Administrator discussed the importance of accurate documentation when reporting incidents into the Department. No deficiencies were cited on today's date. Exit interview was conducted and a copy of this report was emailed to the Administrator, Fenina Pham, with a request for the report to be signed and returned electronically.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Administrator, Fenina Pham


summary: Facility Evaluation

raw_content:
Narrative:
On 12/16/ Licensing Program Analyst (LPA) Mary Shelton conducted an unannounced Annual inspection at 11:49AM and met with Andrew Nguyen, Administrator The home is an Enhanced Behavioral Support Group Home with the requested capacity of four non-ambulatory clients. There is currently one non-verbal client placed in the home. Andrew Nguyen - Administrator who accompanied LPA on an inspection of the facility inside and out. There were no clients present during the inspection due to school. The facility has four bedrooms, two bathrooms, staff office, kitchen, living room, dining room, sensory room, a living space designated for reading, gym, outside area and a three car garage. LPA Shelton inspected and/or reviewed the following: · Postings of facility license and Personal Rights Poster were appropriately posted · Disinfectants/Cleaning solutions were inaccessible and locked as required · Refrigerator Temperature was at or below 45 degrees F and Freezer Temperature at or below 0 degrees. · Nonperishable Foods for one week and fresh perishable foods two days minimum were present · Menu binder was present and accessible in the kitchen · LPA observed a working telephone on the premises · Carbon monoxide detectors and Smoke Detectors were present and functioning · First Aid Kit was present and fully stocked as required · Common Room (living room) was available for clients · Dining area with enough seating for clients in care was present and in good condition · Medication was centrally stored, locked/inaccessible. Centrally stored medication and log reviewed · LPA reviewed five (5) staff files and one (1) client file · LPA conducted interviews with two staff. · Motor Vehicle appeared to be properly maintained. LPA observed lights, tires, registration/insurance and working seat belts at the time of the inspection. · LPA observed that the facility appeared to be free of vermin · LPA reviewed complaint procedures for clients. · Disaster Preparedness was updated and available for review, quarterly drills are completed and logged in a binder and there are disaster preparedness supplies available and verified by LPA · Staff training was in compliance · Criminal record clearances were verified by LPA and in compliance · Staff files reviewed had First Aid Certificates and CPR cards with a valid dates as required · Staff job titles/qualifications were verified along with the required training · Trauma informed practices are implemented as needed (including specialty mental health services and extracurricular activities and social supports) per discussion with the administrator. No citations were issued, and LPA requested the following document from the facility as part of the annual review: LIC Exit interview was conducted and documents were provided to the facility.

visit_type: Annual

met_with: Andrew Nguyen, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 2/18/22, Licensing Program Analyst, (LPA) Connie Goldie conducted an unannounced case management inspection. LPA met with Administrator Interim (AI), Andrew Nguyen at 2: PM . LPA Goldie conducted a walk through of the facility inside and out and observed the following: three bedrooms with a bed, dresser and closet space, one bedroom client declined entry, two bathrooms with soap and towels, three days of perishable and five days of non-perishables, functioning smoke detectors, fire extinguisher, and medication storage. Additionally LPA observed outdoor area free of hazards. LPA Goldie conducted two staff interviews, reviewed one client file and observed medication preparation. LPA requested training documents for one staff, MAR sheets for February 5, 2022. No citations were given today. LPA conducted exit interview with (AI) and thanked him for his time.

met_with: Administrator Interim


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 12/28/2022, at 11: AM, Licensing Program Analyst, (LPA) Connie Goldie made an unannounced visit to conduct an Annual/random inspection. LPA Goldie was greeted at the door by Lead DSP II, Jules Auditor. Program Administrator Interim (PA) Andrew Nguyen assisted LPA Goldie with the inspection. Six staff and 3 clients were present in the home. LPA Goldie observed the following during the inspection of this single story home: The yard is clean. A board with nails exposed and an electrical outlet attatched was loose on the ground. A work order was submitted by PA.. Screens are in good repair. The garage contained an additional refrigerator, outdoor equipment and chemicals in locked cabinetry. There is adequate indoor and outdoor activity space. Sharps are inaccessible to clients as required. Locked and centrally stored medications along with a complete first aid kit were observed. The facility has 4 single occupancy bedrooms and two client bathrooms. Adequate supply of linens and bedding were observed. Bedrooms are accommodating of all required furnishings. The dining room has a large table with chairs to accommodate all clients. Carbon monoxide detector and fire extinguishers with pins in place observed and tested. Facility maintains a current fire clearance. Appropriate forms posted in view included license, Client register, and Emergency Intervention Plan. Kitchen observed to have 2 days of non-perishables and 5 days of non-perishables. Temperature was a comfortable 73 degrees . Water temperature measured 113, within compliant range of 105 degrees and 120 degrees. Hygiene supplies were observed in closet along with additional linens and towels. 5 staff interviews and 8 staff record reviews were completed. Type A and Type B Title 22 violations were cited. Technical Violation was given. This is not deficiency. Exit interview conducted at 5: PM and reports discussed and provided to facility.

Deficiencies:
84079(a): Planned Activities

(a) The licensee shall develop, maintain, and implement a written plan to ensure that indoor and outdoor activities which include but are not limited to the following are provided for all children

met_with: Administrator Interim Andrew Nguyen


summary: Facility Evaluation

raw_content:
Narrative:
On 12/28/2022, at 11 : AM, Licensing Program Analyst, (LPA) Connie Goldie conducted an unannounced visit to complete a random annual. LPA Goldie met with Program Administrator Interim (PA) Andrew Nguyen to assist with the inspection. LPA Goldie completed a walk through of the facility, interviewed 5 staff and reviewed 8 staff records. Due to technical difficulties, CARE tools and LIC809 were unable to be accessed. LPA Goldie will return at a later date to complete Annual. No deficiencies were cited during today's visit. LPA Goldie conducted exit interview at 5 PM and left a copy of the report along with appeal rights at the facility.

met_with: Andrew Nguyen, Program Administrator Interim


summary: Facility Evaluation

raw_content:
Narrative:
On 01/12/2023, at 10: AM, Licensing Program Analyst (LPA) Connie Goldie met with Program Administrator Interim (PA) Andrew Nguyen to continue unannounced/random Annual inspection. PA Nguyen stated that five staff are currently in the facility. All clients are at school. On 12/28/2023, LPA attempted to interview verbal client and he denied. All 3 clients were observed in home engaging with staff as well. Client files were reviewed and medication assessment was completed during today's inspection. Title 22 violations were observed during record review. Four Type B violations are being cited. See LIC809D for deficiencies observed. An exit interview was conducted with PA Nguyen at 12: PM and a copy of the report along with appeal rights was left at the facility. .


summary: Facility Evaluation

raw_content:
Narrative:
On this date, Licensing Program Analyst (LPA) Connie Goldie conducted a case management inspection at the facility. The purpose of the inspection was to inquire about two incidents that were reported to the Department on 04/02/2023 and 04/03/2023. LPA met with Andrew Nguyen, Program Administrator, (PA) who helped facilitate the inspection. LPA inquired about medication error incident that occurred on 04/02/2023, the second medication error to happen within 30 days. and the elopement that occurred due to lack of supervision on 04/01/2023.Program Administrator informed LPA of staff who were involved for both incidents. 4 staff interviews were conducted. Further investigation is required. An exit interview was completed and a copy of this report was provided to facility.

met_with: Andrew Nguyen Program Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 08/16/2023,at 03: PM, Licensing Program Analyst (LPA) Connie Goldie conducted a case management inspection at the facility. The purpose of the inspection was to inquire about an incident that was reported to the Department on 08/13/2023. LPA met with Andrew Nguyen, Program Administrator, (PA) who helped facilitate the inspection. LPA conducted a walk through of home inside and out. LPA observed 4 individual youth bedrooms with appropriate bedding and furnishings. Kitchen had perishables and non-perishables compliant to regulation. Bathrooms were observed to have soap and paper products as required. Smoke/carbon-monoxide detectors were tested and compliant. Fire extinguisher observed to be recently serviced. Living/ dining areas have seating appropriate to meet residents needs. All screens were observed to be clear of tears. Backyard area clear of debris. LPA conducted one interview. Further follow-up is required to resolve case management. LPA Goldie provided a copy of report along with appeal rights to Program Administrator.

met_with: Program Administrator, Andrew Nguyen


summary: Facility Evaluation

raw_content:
Narrative:
On 10/04/2023, at 12: PM, Licensing Program Analyst, (LPA) Connie Goldie conducted an unannounced visit to follow-up on Case Management inspection conducted on 08/16/2023. One client and 5 staff were present at facility upon arrival. Program Administrator, (PA), Andrew Nguyen assisted with inspection. LPA toured home with PA and observed blinds in bedroom 5 as broken due to behavior of client. PA stated it will be repaired by Friday,10/06/2023. LPA observed them to not be a safety hazard at this time. Case Management inspection pertained to incident report received by the Department on 08/13/2023 which involved C1 obtaining batteries out of a toy and placing them in his mouth. On 08/16/2023 and 08/28/2023, LPA conducted interviews with two staff and learned C1 was in his bedroom enjoying privacy when incident occurred and the staff had no reasonable basis to believe C1 was unsafe. Staff took appropriate action by calling poison control and did take C1 to the hospital to ensure he was safe. Based on the fact that staff are now aware of this potential a technical advisory is being issued. This is not a deficiency. An exit interview was conducted with Mr.Nguyen and a copy of this report along with appeal rights were provided.

met_with: Program Administrator Andrew Nguyen


summary: Facility Evaluation

raw_content:
Narrative:
At 03: PM on 11/21/2023, Licensing Program Analyst (LPA) Connie Goldie made an unannounced Case Management - Incident inspection to the facility listed above.The purpose of the inspection was to inquire about an incident report that was received by the Department on 11/03/2023 for an incident that occurred in the community on 11/01/2023. Program Administrator, (PA) Andrew Nguyen assisted with the inspection. Additionally, two clients, 2 direct care staff, 1 lead staff and a shadow staff were present during visit. One client is on an outing and another is on a home visit. A walk through of the facility was completed and no deficiencies were observed. Two interviews were conducted. At this time, further review is needed for this Case Management. An exit interview was conducted and a copy of this report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/14/2023, at 09: AM, Licensing Program Analyst, (LPA) Connie Goldie made an unannounced visit to conduct an Annual/Required inspection. LPA Goldie was greeted at the door by Program Administrator, Andrew Nguyen who assisted LPA Goldie with the inspection. 5 staff and 0 clients were present in the home. LPA Goldie observed the following during the inspection of this single story home: Documentation required posted in office included License, Client roster, and Emergency Disaster plan. Grievance forms were observed to be accessible to residents in hallway adjacent to office door. There is adequate indoor and outdoor activity space. The spacious living room included seating for residents and staff as well as guests to engage with one another. Sharps are inaccessible to clients as required in a locked drawer in kitchen. Locked and centrally stored medications along with a complete first aid kit were observed. The facility has 4 single occupancy bedrooms and two client bathrooms. Water tested in bathroom #2 and kitchen measured 122 degrees which is not in compliance range of 105 degrees to 120 degrees. Program Administrator adjusted the water heater and afterwards, temperature measured at 115 degrees. Adequate supply of linens and bedding were observed. Bedrooms are accommodating of all required furnishings. Bedroom four was observed to be missing a top sheet. The dining room has a large table with chairs to accommodate all clients. Carbon monoxide detector and fire extinguishers with pins in place observed and tested. Facility maintains a current fire clearance. Kitchen observed to have 2 days of perishables and 5 days of non-perishables. Temperature was a comfortable 74 degrees. Hygiene supplies were observed in closet along with additional linens and towels. 4 staff interviews and 5 staff record reviews were completed. Type B Title 22 violations are being cited during today's inspection. Additionally, Technical Violations are being issued. These are not deficiencies. LPA will return to complete Annual inspection on a later date. Exit interview conducted at 5: PM and reports discussed and provided to facility.

met_with: Andrew Nguyen


summary: Facility Evaluation

raw_content:
Narrative:
On 01/25/2024, Licensing Program Analyst, (LPA) Connie Goldie made an unannounced subsequent visit to complete Annual required inspection at 2: PM. LPA Goldie completed client record review domain in Care Tools including medication review of Medical Administration Records. LPA completed 4 client interviews using IPP and observation as consumers are non-verbal. During inspection four Type B Title 22 regulation violations were cited. See LIC809D pages. Two technical violations were issued. These are not deficiencies. Annual Required inspection is complete. Exit interview was conducted with Program Administrator and reports along with appeal were discussed and provided.


summary: Facility Evaluation

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Narrative:
On 06/19/2024 at 09: AM, an unannounced case management inspection was conducted by Licensing Program Analyst, (LPA), Connie Goldie to follow up on Waiver rescission issued on 06/14/2024 and received by facility on 06/17/2024. LPA Goldie met with Andrew Nguyen ,Program Administrator. (PA) who assisted with the inspection. 5 staff and 4 youth are present. LPA conducted a walk through of the facility with PA Nguyen. LPA observed the cameras to no longer be in C1's bedroom as requested by the Department. No deficiencies were observed. An exit interview was completed at 10: AM with Mr. Nguyen and a copy of this report was provided to the facility.


summary: Facility Evaluation

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Narrative:
On 10/21/2024 at 03: PM, Licensing Program Analyst (LPA) Connie Goldie, Behavior Specialist, Amir Cruz-Khalili and Qualified Behavior Modifcation Professional, Jenna Rhodes conducted a case management inspection at the facility. The purpose of the inspection was to inquire about three incidents that were reported to the Department on 10/09/2024 and 10/11/2024. LPA met with Administrator, (PA) who helped facilitate the inspection. 1 resident and 6 staff are present in the facility. During inspection three additional residents arrived. LPA completed a walk through of the facility inside and outside. LPA conducted one interview. Further follow-up is required to resolve case management. LPA Goldie provided a copy of report to Ms. Pham, Program Licensee.

met_with: Fenina Pham Licensee


summary: Facility Evaluation

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Narrative:
On 11/14/2024 at 02: PM, Licensing Program Analyst (LPAs) Connie Goldie and Michelle Silvas conducted an unannounced case management inspection at the facility. The purpose of the inspection was to inquire about an incident that was reported to the Department on 10/24/2024. LPA met with Joha Thomas, Lead who helped facilitate the inspection. Six staff are present in the facility. During inspection two residents arrived. LPA completed a walk through of the facility inside and outside. LPA conducted two staff interviews. LPA requested staff schedule for October 2024 and staff contact phone numbers. Further follow-up is required to resolve this case management. LPA Goldie provided a copy of report to Ms Thomas, Lead staff.

met_with: Jo


summary: Facility Evaluation

raw_content:
Narrative:
On 11/14.2024 at 04: PM, Licensing Program Analyst (LPA) Connie Goldie, made an unannounced subsequent case management inspection at the facility. The purpose of the inspection is to conduct interviews pertaining to incidents that were received by the Department on 10/09/2024 and 10/11/2024. LPA met with Joha Thomas, Lead Staff, who helped facilitate the inspection. Three clients and six staff are present in the facility. One additional client arrived during inspection. LPA completed a walk through of the facility inside and outside. See LIC812 for details. LPA conducted five interviews. Further follow-up is required to resolve case management. LPA Goldie provided a copy of this report to , Benjamin Rimorin, Administrator.

met_with: Joha Thomas, Lead Staff Benjamin Rimorin, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 12/5/2024, at 10: AM, Licensing Program Analysts, (LPAs) Michelle Silvas and Connie Goldie made an unannounced visit to conduct an Annual/Required inspection. LPAs Silvas and Goldie were greeted at the door by Program Administrator, Benjamin Rimorin who assisted LPAs Silvas and Goldie with the inspection. 2 staff and 0 clients were present in the home. LPAs Silvas and Goldie observed the following during the inspection of this single story home: Documentation required posted in office included License, Client roster, and Emergency Disaster plan. Copies of the LIC 500 and LIC 610C and the roster of Minors were requested and received. Grievance forms were observed to be accessible to residents in hallway adjacent to office door. There is adequate indoor and outdoor activity space. The spacious living room included seating for residents and staff as well as guests to engage with one another. Sharps are inaccessible to clients as required in a locked drawer in kitchen. Locked and centrally stored medications along with a complete first aid kit were observed. The facility has 4 single occupancy bedrooms and two client bathrooms. Water tested in bathroom #1 measured at 108 and kitchen measured 106 degrees which is in compliance range of 105 degrees to 120 degrees. Adequate supply of linens and bedding were observed. Bedrooms are accommodating of all required furnishings. The dining room has a large table with chairs to accommodate all clients. Dual smoke and Carbon monoxide detectors and fire extinguishers with pins in place observed and tested. Facility maintains a current fire clearance. Fire doors are currently not functioning but a work order has been submitted. Kitchen observed to have 2 days of perishables and 5 days of non-perishables. Temperature was a comfortable 68 degrees. Hygiene supplies were observed in closet along with additional linens and towels. All three vans were inspected and tires have good tread, seat belts working properly and all signal lights functioning properly. One van was missing a first aid kit and the other two need replenishment. Type B Title 22 violation is being cited during today's inspection. Additionally, Technical Violation is being issued. This is not a deficiency. LPAs will return to complete Annual inspection on a later date. Exit interview conducted at 3: PM and reports discussed and provided to facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/06/2024, Licensing Program Analysts, (LPAs) Michelle Silvas and Connie Goldie made an unannounced subsequent visit to complete the Annual required inspection at 10: AM. LPAs Silvas and Goldie completed staff and client record review domains in the Care Tools including medication review of Medical Administration Records. LPAs completed 5 staff interviews. During the inspection, five Type B Title 22 regulation violations were cited. See LIC809D pages. One technical assistance was issued. This is not a deficiency. Annual Required inspection will be finalized upon the completion of the 4 client interviews. Exit interview was conducted with Program Administrator and reports along with appeal rights were discussed and provided.


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst, Michelle Silvas, met with Benjamin Rimorin, Administrator, to deliver an Order to Licensee/Facility of an Immediate Exclusion from Facility letter. LPA was advised that the staff mentioned on the Immediate Exclusion, Joha Thomas, is no longer employed or associated to the facility . LPA hand delivered to Benjamin the Order to Licensee/facility of Immediate Exclusion from Facility. An exit interview was conducted, and a copy of this report was provided.


summary: Facility Evaluation

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Narrative:
On June 4, 2025, at 10: AM, Regional Manager, Margo Castaneda, Licensing Program Manager (LPM) Jodean Hall, Licensing Program Analyst (LPA) Michelle Silvas conducted a Non-Compliance Review Meeting in the Sacramento Regional Office. The purpose of the office meeting is to discuss some serious concerns related to recent complaint findings and other compliance concerns identified. The following NCC primary areas of concern were reviewed: lack of oversight of the facility, staff to child ratio, medication errors and lack of leadership. The compliance for Polaris: was reviewed for the time period of March 2023- May 2025. Operation of the facility was discussed and additional documentation related to the operation of the facility and compliance plan is documented on the LIC9111. A copy of this report was sent to Fenina Pham, Owner of LLC, for signature.

met_with: Fenina Pham Owner of LLC & Benjamin Rimorin Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On September 5, 2025, at 02:30PM, Licensing Program Analyst (LPA) Michelle Silvas arrived at the facility to initiate an unannounced case management inspection. LPA met with Margarita Hernandez, Lead, who assisted with today's inspection. 4 staff and 0 clients are present. The purpose of today's visit is to follow up on concerns that North Bay Regional Center had after conducting an unannounced visit on 8/28/25 and 8/29/25. An inspection of the facility was conducted inside and out. LPA took pictures of the menu,inside the refrigerators, van binder log and van's interior. Three staff interviews were conducted. Further investigation is needed at this time. An exit interview was conducted. A copy of this report was given to Margarita Hernandez, Lead.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced case management inspection at the facility and met with Administrator Benjamin Rimonrin, who assisted with the inspection. LPA conducted a walk through of the facility with Administrator and observed: the facility was clean, with no visible hazards. There were perishable foods and non perishable foods that met the regulation standard. The facility is following the client's religious food preferences. The client has 12 available underwear at the facility. LPA reviewed the clients' medication and MARs with Administrator, and all records matched all medications, which were administered on the correct dates and times. LPA obtained the staff roster with staff contact information. The facility plans to close on 11/8/2025 and both clients will be discharged from the facility on 10/27/2025. CCL is in receipt of the facility's closure plan. The clients were present during the inspection, however are non-verbal. No deficiencies were observed or cited during the inspection. This case management is concluded. An exit interview was conducted with Administrator and a copy of this report was provided to him.

met_with: Benjamin RImonrin


summary: Facility Evaluation

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Narrative:
On April 22, 2025, at 11:00AM, Licensing Program Analyst (LPA) Michelle Silvas and Licensing Program Manager (LPM) Jodean Hall, arrived at the facility to initiate an unannounced case management inspection. LPA and LPM met with Benjamin Rimorin, Administrator, who assisted with today's inspection. 5 staff and 1 client are present. The purpose of today's visit is to conduct an SIR follow up on the following SIRs the Department received: 2/28/25, 4/10/25, 4/12/25 and 4/18/25. An inspection of the facility was conducted inside and out. A file review was conducted and the following copies were obtained: C1, C2, C3 most current IBSP plans and IPP plans. There were 4 staff interviews conducted. No client interview were conducted as the clients are all nonverbal. It was observed that there was not enough fresh fruits and vegetables for the clients in care. LPA and LPM discussed healthier options and will be issuing the facility a technical advisory. This is not a citation. The facility will be issued 3 citations today and one technical assistance, this is not a citation. one Type A and two Type B violations. It was observed on 4/16/25 by DDS that there were broken cabinet doors and drawers in the kitchen and a hole in the wall by the laundry room. On 4/17/25, LPA observed the broken cabinet doors and drawer in the kitchen and the hole in the wall. by the laundry room. On 4/16/25, upon the arrival to the facility by DDS, they observed the facility to be out of ratio, there were three staff when there should have been six. Continue LIC809-C Regarding an SIR that was received by the Department on 4/18/25, it was documented that a S1 took C1 on a van ride alone when C1 is a 2:1 ratio in the van. An exit interview and appeal right were discussed with Benjamin Rimorin, Administrator. A copy of this report along with the appeal right were given to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On May 7, 2025, at 11: AM, Licensing Program Analyst (LPA) Michelle Silvas arrived at Polaris Homes to initiate a plan of correction visit. LPA met with Margarita Hernandez, Lead who assisted with today's inspection. LPA conducted a walk through of the facility inside and out. Three staff are present and no clients are present. Administrator Benjamin Rimorin arrived at the facility at 1: PM and assisted LPA. LPA observed the broken cabinet doors and drawers in the kitchen to not be repaired. The facility has failed to correct the deficiency by the due date of May 6, 2025. An immediate Civil penalty is being assessed today in the amount of $250, and the Civil Penalty will continue to accrue at $100 per day until the deficiency is corrected. An exit interview and appeal rights were discussed with Benjamin Rimorin, Administrator and a copy of this report along with the appeal rights were given.


summary: Facility Evaluation

raw_content:
Narrative:
On May 16, 2025, at 09:20AM, Licensing Program Analyst (LPA) Michelle Silvas arrived at the facility to initiate an unannounced case management inspection. LPA met with Benjamin Rimorin, Administrator, who assisted with today's inspection. 6 staff and 0 clients are present. The purpose of today's visit is to conduct a medication review and staff file review due to concerns made by the North Bay Regional Center's visit on May 15, 2025. An inspection of the facility was conducted inside and out. Seven staff files were reviewed and three clients Psychotropic Medication Record (PMAR) and Medication Administration Record (MAR) were reviewed. Upon review of the medication logs for all three clients, there were errors within the logs. C1 had wrong prescription numbers, refill dates and refill amounts for three medications. C2 had a missing MAR and one expired medication. C3 had incorrect filled dates for two medications, three extra refills for one medication in the medication drawer, one expired medication and no MAR for one medication. The facility is being cited one Type B violation Title 22, Division Chapter Article 06. Continuing Requirements. An exit interview and appeal rights were discussed. A copy of this report along with appeal rights were given to Benjamin, Rimorin, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On October 3, 2025, at 01:00PM, Licensing Program Analyst (LPA) Michelle Silvas arrived at the facility to conduct a case management inspection. LPA met with Benjamin Rimorin, Administrator, who assisted with today's inspection. 3 staff and 0 of clients were present. LPA conducted a case management inspection on September 5, 2025, to follow up on concerns that North Bay Regional Center had after conducting an unannounced visit on 8/28/25 and 8/29/25. On September 19, 2025, LPA inspected the facilities van that is used to transport clients. LPA observed the van to have a foul odor like someone had a bowel movement and soiled the seat, stains on the seats, a plastic bag that had old food in a container, garbage on the floor and behind the seat back pocket. The ceiling of the van is torn, ripped off and all the vent covers are missing, exposing the vent holes. LPA requested staff to turn the van on and turn the air conditioning on. LPA did not feel any air flowing through the vents in the back of the van. LPA asked staff how long the air conditioning in the back of the van had not been working? Staff stated, "for a while". Due to the conditions in the vehicle, the facility was issued a type B citation for Title 22, Division 6, Chapter Article 06. Continuing Requirements. An exit interview was conducted, and appeal rights were discussed. A copy of this report was provided.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Connie Goldie made an unannounced case management visit and met with Lead Staff Isha Dhaliwal.Lead staff conducted the walk through.The purpose of the visit is to deliver findings of deficiencies observed during a previous inspection date on 2/18/22. Program Administrator Interim (PAI) Andrew Nguyen arrived a t PM and LPA Goldie delivered findings to him. LPA Goldie conducted a walk through of the facility with Lead Staff Dhaliwal both inside and out and observed the following: A living room, reading area room, a sensory room, 4 individual client bedrooms with dresser, bed and desk (two of which are occupied), 2 bathrooms with appropriate amounts of soap and towels, 3 days of perishables and five days of non-perishables, 9 working smoke detectors / carbon dioxide monitors inside. LPA Goldie observed a gym area as well as equipment for the clients and no hazards outside. On 2/18/2022, LPA Goldie identified during an interview with S1, that S1 was not trained on medication dispersal prior to being responsible for passing medication. This resulted in a client receiving two 3 mg dosage at one time instead of one 1 mg and one 2 mg dosage during morning medication violating C1's personal rights. The PAI verified that S1 was not trained prior to administering medication during records review of S1's file. LPA Goldie also observed during inspection on 2/18/22 that two cameras were installed in C1's bedroom and active prior to approval from CCL. A waiver is pending but, has not been approved yet. The initial waiver request was sent by Program Administrator Fenina Pham and received by the Department. On this date the facility is being cited for the following violation of Title 22, Division 6 , Chapter 5 found during case management inspection on 2/18/2022 ,Personnel Requirements, Medication Training 84065 (3) (m). Additionally, the facility is receiving a technical violation for proceeding with camera installation prior to a waiver being approved. An exit interview was completed and a copy of this report along with appeal rights was left at the facility.

met_with: Lead Staff Isha Dhaliwal and Administrator Program Adminstrator Interim Andrew Nguyen


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Connie Goldie made an unannounced case management visit and met with Andrew Nguyen Interim Program Administrator(PA). The purpose of the visit is to discuss Incident Report dated 11/06/2022. One client is currently at home due to illness and 4 staff are present. LPA Goldie conducted a walk through of the facility with PA Nguyen both inside and out and observed the following: A living room, reading area room, a sensory room, 4 individual client bedrooms with dresser, bed and desk (three of which are occupied), 2 bathrooms with appropriate amounts of soap and towels, 3 days of perishables and five days of non-perishables, LPA Goldie observed a gym area as well as equipment for the clients and no hazards outside. LPA observed property damage from behaviors that occurred on 12/10/22 and 12/11/22. The broken window in the office is boarded. Holes in walls have been patched. Kitchen cabinetry has been removed. Work orders for damage were submitted 12/10- 12/12 and property management has been to facility and made everything safe. LPA Goldie conducted two staff interviews. Based on information obtained, the following is being cited. California Code of Regulations, Title 22, Division 6, Chapter 5 84072 (d) (11) , is being cited on the attached LIC 9099D." LPA Goldie conducted an exit interview at 1: PM. A copy of this report along with appeal rights were discussed and provided to PA Nyugen.


summary: Facility Evaluation

raw_content:
Narrative:
At 11: AM on 03/28/2023, Licensing Program Analyst (LPA) Connie Goldie made an unannounced Case Management - Incident inspection to the facility listed above. The reason for the inspection is to review an incident that took place involving a medication error. LPA met with Andrew Nguyen, Program Administrator (PA) who helped facilitate the inspection. LPA Goldie toured facility with PA and observed a single story home with four individual bedrooms with clean linen and adequate furniture , two bathrooms with soap and towels, kitchen with 2 days of perishables and 5 days of non- perishables, sharps and medication were inaccessible. Laundry appliances were observed to be in good repair, Living room . reading nook, and dining area had sufficient seating and were observed to be inviting areas for clients in care. Fire detectors and carbon monoxide were tested and compliant. Outside was toured and observed to be free of hazards/debris.r. LPA inquired about incident that occurred on 03/19/2023 involving a medication error resulting in youth being taken to emergency room. PA stated medication was prepped for all clients at the same time due to a staff member calling out sick and a staff running late. Preparing medication for more than one client at a time is not part of medication protocal /procedures.. Additionally, staff member that passed medication was the verifier and not the passer. Two staff interviews were conducted that corroborated that both of these led to medication being passed to wrong client and client needing to be taken to Kaiser Emergency Room at Quality Drive Vacaville, CA 95688. Facility is being cited for Title 22, Division Chapter 1 80075(b) (5) (B) Health Related Services deficiency. See LIC809D. Exit interview was conducted with Program Administrator and a copy of report along with appeal rights were discussed and provided.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Connie Goldie made an unannounced Case Management visit to the facility. LPA spoke to Program Administrator, (PA) Andrew Nguyen regarding a case management involving two incident reports (IR) which occurred on 04/01/2023 and 04/02/2023. IR #1 stated C1 eloped from facility due to lack of supervision. LPA interviewed 4 staff and the PA who all corroborated that C1 is a 1:1 client and there was a lapse of supervision when S4, (C1's assigned staff at the time) used the restroom and did not ensure another staff was supervising C1. As a result, C1 eloped and left through an open garage door. C1 was not discovered to be missing by staff but, by individual at community store. C1 must be within the line of sight of a staff to be kept safe, as he has a history of elopement IR# 2 stated a medication error occurred. PA and staff involved confirmed a medication error occurred due to S1 misreading Medication Administration Record (MAR) and S3 not catching error when verifying medication preparation. Additionally, medication change form was removed from staff sign in area so S1 did not observe it. Lastly, the MAR did not have a black mark to decease previous dosage because date of change was on the last day of March. Based on LPA's interviews and the incident reports, two Title 22 deficiencies are being cited. 80075 (b)(5) (B) and 84078 (b) One civil penalty is being assessed for repeat violation within 30 days. An exit interview was conducted with PA, Andrew Nguyen and a copy of this report was left at the facility


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Connie Goldie made an unannounced Case Management visit to the facility at 01: PM. LPA spoke to Program Administrator, (PA), Andrew Nguyen, regarding a case management involving an incident report dated 09/19/2023. The incident report stated client (C1) had left facility without authorization and was unobserved by assigned staff. C1 requires 1:1 supervision and staff did not maintain supervision resulting in C1 being in an unsafe situation. The lack of supervision resulted in client leaving facility grounds and law enforcement ensuring safety. The client's location was unknown for approximately 15 minutes. LPA interviewed two staff and reviewed employee disciplinary notice for S1. Based on LPA's interviews and the incident report, one deficiency is being cited, 80078 (a), Responsibility for Providing Care and Supervision. An exit interview was conducted with PA, Andrew Nguyen, and a copy of this report was left at the facility along with appeal rights..


summary: Facility Evaluation

raw_content:
Narrative:
On 12/06/2023 at 1: PM, an unannounced case management inspection was conducted by Licensing Program Analyst, (LPA), Connie Goldie to follow up on a visit to the facility conducted on 11/21/2023. LPA Goldie met with Margarita Hernandez, Lead staff, who assisted with the visit. During phone call with Andrew Nguyen, Program Administrator on 11/09/2023, LPA learned that C1 was in the community with only one staff which wasn't compliant with ratio determined necessary in C1's Individual Program Plan as C1 requires a 2:1 staff to client ratio in the community. As a result, C1 ran away and was unsafe in the community without supervision for an hour and a half. During visit to facility on 11/21/2023, LPA conducted 2 staff interviews and both staff stated that procedures in place to ensure safety of C1 were not followed. LPA interviewed a witness who stated that incident of C1 being unsafe in the community, without supervision, could have been avoided if staff followed the rules. The agency is being cited for one Title 22, Division 6, Chapter 5, Article 6, violation Responsibility for Providing Care and Supervision 84078(b). An exit interview was conducted where the citation and plan of correction were discussed. Appeals rights were provided and discussed with the facility representative mentioned above.

met_with: Margarita Hernandez Lead staff


summary: Facility Evaluation

raw_content:
Narrative:
On 01/07/2025, at 09: AM , Licensing Program Analyst, (LPA), Connie Goldie, made an unannounced, subsequent visit for the purpose of closing out a Case Management, regarding incidents that were reported to the Department on 10/11/2024, 10/14/2024 and 10/24/2024.LPA met with McKenzie Jeppson, Registered Behavior Technician . LPA interviewed the licensee and five staff members for an incident reported on 10/24/2024 and the licensee and ten staff members for the incidents reported on 10/11/2024 and 10/14/2024. Based on interviews and review of incident reports, it was identified that the incidents reported on 10/11/2024 were reported 2-3 months after observation by S2 and on 10/14/2024 2-3 weeks afterwards by S8 and therefore, the facility was out of compliance with reporting requirements. S2 and S8 both admitted to not reporting timely as required. Three staff members stated they did not have training on reporting requirements that they understood until a month ago. Additionally, three staff (S3, S4 and S7) stated the trampoline was used to isolate a client, C1, as the netting was zipped and clipped. It was stated that S3 and S8 did this. This is a personal rights violation. The facility is being cited for two Title 22 deficiencies, Reporting Requirements 80061(b) and Personal Rights 84072(d)(1). See LIC809D. Fenina Pham, licensee, provided the plan of correction via telephone. The case management is closed. No follow-up investigation is required. An exit interview was conducted and a copy of this report and appeal rights were discussed and provided to McKenzie Jeppson, Registered Behavior Technician.


raw_content:
Narrative:
LPA conducted interviews with two staff and one client's teacher, and it was learned staff would sometimes not remember to switch out the previous day's dirty clothes for clean, but when the school asked for more or would have to contact the facility to bring clean clothing to facilitate changes, the facility would provide them. During LPA's inspection at the facility on 10/23/2025, LPA and Administrator observed there to be 12 total changes of underclothing for the client but that sometimes during the laundering of clothing, clothing items were mixed up with other clients in the home. Regarding the staffing, interviews with facility staff informed LPA that towards the end of the facility being open, many staff quit or called out frequently, leaving the facility short-staffed. However, other staff, lead staff, and the Administrator would cover these shifts to prevent the facility from being out of ratio, but this left them down the lead staff as a result. While the facility attempted to use an agency to provide qualified staff to fill in, staff were frequently not available. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with the Licensee and a copy of this report and appeal rights was provided to them. By reviewing the pictures, LPA observed the refrigerator to be almost empty and the freezer had only a few items in it. In addition, one staff informed LPA that when the Regional Center staff were present, there was not enough to meet minimum requirements. During LPA's initial inspection at the facility on 10/14/2025, the facility had already purchased more food and was in compliance but during the inspection conducted by the Regional Center on 10/7/2025, it was not. Based on observations, the preponderance of the evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 5, Section 84076(c)(1) Food Service is being cited on the attached LIC 9099D. An exit interview was conducted with the Licensee and a copy of this report and appeal rights were provided to them.

Investigation Findings:
13On 4/1/2026 at 9: AM, Licensing Program Analyst (LPA) Alyssa Burgess met with Licensee Fenina Pham at the CDSS Sacramento Regional Office to deliver the findings of this complaint. LPA investigated this complaint by reviewing visit summaries/emails, pictures taken at the facility, staff schedules and by conducting interviews with the Administrator, Licensee, four staff, and a client's Teacher between 10/23/2025 and 3/20/2026. The clients of the facility were not able to be interviewed due to their diminished capacity for communication. During an inspection conducted by the North Bay Regional Center on 10/7/2025, it was observed that there was not the required minimum amount of food present in the facility. Pictures were taken by North Bay Regional Center staff and provided to LPA. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Jensen-Hill LICENSING EVALUATOR NAME: Alyssa M Burgess LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE This is an official report of an unannounced visit/investigation of a complaint received in our office on 10/09/2025 and conducted by Evaluator Alyssa M Burgess PUBLICCOMPLAINT CONTROL NUMBER: 23-CR- FACILITY NAME:POLARIS HOMEFACILITY NUMBER: ADMINISTRATOR:BENJAMIN RIMONRINFACILITY TYPE: ADDRESS: LOCKE ROADTELEPHONE: (707) 514- CITY:VACAVILLESTATE: CAZIP CODE: CAPACITY:0CENSUS: 0DATE: 04/01/ UNANNOUNCEDTIME BEGAN: 09: AM MET WITH:Fenina PhamTIME COMPLETED:10: AM 9Client in the facility does not have the required clothing to meet the needs of a client in care. Facility is not staffing the facility to meet the needs of youth in care. INVESTIGATION FINDINGS: 13On 4/1/2026 at 9: AM, Licensing Program Analyst (LPA) Alyssa Burgess met with Licensee Fenina Pham at the CDSS Sacramento Regional Office to deliver the findings of this complaint. LPA investigated this complaint by reviewing visit summaries/emails, pictures taken at the facility, staff schedules and by conducting interviews with the Administrator, Licensee, four staff, and a client's Teacher between 10/23/2025 and 3/20/2026. The clients of the facility were not able to be interviewed due to their diminished capacity for communication. The allegation that a client did not have the required clothing to meet their needs is related to reports that one client did not have the required underclothes to facilitate changing at school when needed. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Jensen-Hill LICENSING EVALUATOR NAME: Alyssa M Burgess 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: POLARIS HOMEFACILITY NUMBER: VISIT DATE: 04/01/2026

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

met_with: Fenina Pham


facility_name: TURNING POINT- AVALON

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
out of 11 interviews stated that the staff at the facility were being dignified and giving the youths at the facility respect. 2 of 3 youths placed at the facility state that the staff treat them well and that they have no complaints with the staff. Secondly, based on records review, it is noted that C1 does have a history of not telling the truth, attempting to control others, or manipulating others to get their way. Also, the Service Coordinator for the youth in question has no concerns for the treatment of the youth in the facility. Although the allegation may have happened or is valid there is not a preponderance of evidence to prove the alleged violation did occur therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, and Appeal Rights were discussed with Shadayleon Walker, Facility Administrator Assistant. A copy of this report and Appeal Rights were left at the facility.

Investigation Findings:
13On 11/21/ Licensing Program Analysts (LPAs) Sara Luman-Gonzalez & Orlando Areizaga conducted an unannounced visit to the above agency to deliver the findings of a complaint investigation. LPAs met with Shadayleon, Walker, Facility Administrator Assistant and was granted entry. During the investigation, LPA Luman-Gonzalez conducted the 10-day inspection of the facility on 8/5/2024. LPA obtained Client Facesheet, Admission Packet, IBSPs, Email and Text Message correspondence between the Responsible Parties and the Facility, Staff Schedule, Contact information for all staff, and Case notes for the month of July 2024. 11 confidential interviews were conducted between August 2024 and November 2024 by LPA Luman-Gonzalez. Based on Interviews conducted during the investigation process, LPA received inconsistent statements on whether staff taunted youths in care. (Cont. on LIC 9099C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Sara Luman-Gonzalez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: TURNING POINT- AVALONFACILITY NUMBER: VISIT DATE: 11/21/2024


summary: Facility Evaluation

raw_content:
Narrative:
On 7/14/22 at 9:00am, Licensing Program Analyst (LPA) Stephanie Lor and Licensing Program Manager (LPM) Rosa Rodriouez conducted a Pre-Licensing Inspection, Component II and Component III at the above facility. LPA Lor and LPM Rodriguez met with the Regional Program Director and Cheryl Gutierrez. The facility consisted of a formal living room equipped with a set of 3 couches, a formal dining room equipped with a large table with 6 chairs. There is a resting area/second living room area equipped with a TV and board games. The kitchen was equipped with counter space with 4 stools, locked cabinets to store the sharp objects/knives and dish soaps, plates, utensils, cups, silverware, and a large trash can with lid on. 2 office rooms, one room will be used for staff and to lock the files and medication. The second office (the garage) will be utilized by the Administrator. There are 4 bedrooms equipped with a full size beds, closet (curtain will be installed) dresser, night stand, trash can with lid, 2 1/2 bathrooms, one bathroom is for ambulatory clients and the second bathroom is built especially for non-ambulatory clients. Laundry room equipped with a washer/dryer and lock cabinets to store the laundry soap. There is an open back patio, backyard with a basketball court, and a gated section in back for gardening, The front yard was clean and free of hazards. The telephone land line and internet service were in working order. The water temperature was tested and it was between 105 - 120 degrees. There was a little of perishable/non-perishable food available but more will be purchased prior the first placement. During the pre-inspection, LPA Lor and LPM Rodriguez observed the following: 1 first aid kit which was missing the thermometer, and instruction booklet, 2 fire extinguisher located by the main (see 2nd page) entrance, and kitchen area, carbon monoxide and smoke detector were built in throughout the entire house, system was tested and in working condition. Component II was completed during today's inspection and the following areas of the Program Statement were reviewed with the Regional Program Director: Program Description, Client Service, Emergency/Disaster Plan, and Exit Criteria. No additional modifications are needed for the Program Statement. Component III was also completed during today's inspection and the following forms were reviewed with the Regional Program Director: LIC198A -Child Abuse Central Index Check for State Licensed Facilities (family child care homes; children's residential homes and facilities; and adult residential facilities if, through an approved exception or a specialized license, they provide care to a person under age 18), LIC198B - Out-of-State Child Abuse/Neglect Report Request, · LIC 306-Reporting Requirements to Department. of Social Services, LIC 308 - Designation of Facility Responsibility, LIC 500 - Personnel Report, LIC 501 - Personnel Record, LIC 503 - Health Screening Report (including TB Clearance), LIC 508 -Criminal Record Statement, LIC 508D - Out-of-State Disclosure & Criminal Record Statement, LIC 613B - Personal Rights, LIC 624 -Unusual Incident/Injury/Death Report, LIC 627B - Consent for Medical Treatment, LIC 9058 - Applicant/Licensee Rights, LIC 9182 - Criminal Background Clearance Transfer Request, LIC Criminal Record Exemption Transfer Request, Appendix D - A Guide to Safeguarding Resident/Client Cash Resources, LIC 311B - Records to be Maintained in a Group Home, LIC 311E - Records to be Maintained in a Small Family Home, LIC 313 - Evidence of Program Consultant (Group Homes), · LIC Identification and Emergency Information, LIC 602 - Physician's Report for Community Care Facilities, LIC 603 - Preplacement Appraisal Information, LIC 622 - Centrally Stored Medication and Destruction Record, LIC 625 - Appraisal/Needs and Services Plan, LIC 9106 - Group Home Program Statement, LIC 9106A - Short-Term Residential Therapeutic Program (STRTP) Statement General Instructions, LIC 9128 - Foster Family Agency Program Statement, Neighborhood Complaint Policy (see 3rd page) Regional Program Director was instructed to obtain the following items: Thermometer, First Aid Instruction Booklet, and a small refrigerator to utilize if medication needs to be stored in the refrigerator. LPM Rodriguez informed the Regional Program Director that the facility cannot be licensed until CCL received certification from DDS and certification for the Administrator from the Regional Center. Exit interview conducted with Regional Program Director and a copy of the report will be emailed by 07/15/2022.

visit_type: Prelicensing

met_with: Alicia Caroll, Regional Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On 8/10/23, Licensing Program Analyst (LPA) Stephanie Lor made an unannounced visit to the above facility for the purpose of conducting a Post Licensing Inspection. LPA met with the Program Administrator who provided LPA with a tour of the interior and exterior of the facility. LPA observed the following: This facility has 4 bedrooms, 2 living rooms, 2 staff office, kitchen, backyard and 3 bathrooms. LPA observed fixtures and furniture, equipment, and supplies necessary for this operation. LPA observed locked cabinets personnel files to ensure confidentiality. Facility was unable to test out smoke detectors due to the high ceiling, but showed proof of annual testing for the alarms. LPA observed chemicals and sharps to be locked. A first aid kit and fire extinguishers were on site. The water temperature was tested at a safe temperature. LPA Lor observed the agency's license posted in the front entrance. A Technical Assistant (TA) was provided to post up personal rights poster, complaint procedure, and emergency disaster plan in a common area. The agency currently employs one Administrator, one Administrative Assistant, and Direct Support Professionals. The agency currently has one client on site. LPA reviewed one client's file with all required documents. During today's inspection there are no deficiencies cited. An exit interview was conducted, and a copy of this report was provided to the Administrator at the conclusion of the inspection.

met_with: Cheryl Gutierrez, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 8/10/ Licensing Program Analyst (LPA), Stephanie Lor made an unannounced visit to conduct a case management regarding an incident report received by Community Care Licensing for an incident that occurred on 7/19/23 regarding missed medication. LPA met with the Administrator. LPA conducted interviews with the Administrator and provided LPA with copies of training certificate. An exit interview was conducted with the Administrator and a copy of this report will be emailed to the facility. No deficiencies cited. This case management investigation is closed.


summary: Facility Evaluation

raw_content:
Narrative:
On December 18, 2023 at approximately 08: AM, Licensing Program Analysts (LPAs), Farhaan Sarangi and Sara Luman-Gonzalez arrived unannounced at Turning Point-Avalon for the purpose of conducting a Case Management-Other inspection to verify training of facility staff members. During the Case Management-Other inspection, LPAs reviewed a sample of staff records and observed that 1 out of 6 staff members does not have an active First Aid/CPR Card (See LIC 9102-Technical Violation). The remaining 5 staff members have an active First Aid/CPR Card. In addition, LPA reviewed training and observed that 6 of 6 staff members have the required 40 hours of initial training and 20 hours of annual training as outlined in Title 22 regulations. LPA toured the facility and observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. However, LPA did observe a screen that was not on a clients window. Administrator stated that the client took off the screen and that staff members will reinstall it today (See LIC 9102-Technical Advisory) LPA observed sufficient perishable and non-perishable foods. LPA observed that all medications were centrally stored and locked as outlined in Title 22 regulations. Fire Extinguishers were last charged on May 2023. No deficiencies were cited during today's Case Management-Other inspection. Exit interview was conducted, and a copy of this report was signed and given to the Administrator.

met_with: Administrator, Cheryl Gutierrez


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Sara Luman-Gonzalez made an unannounced inspection on May 10, 2024 at 8: A.M. During the inspection LPA met with Cheryl Gutierrez, Facility Administrator who assisted with the inspection. LPA conducted a walk-through of the facility inside and out. There were 4 present and 0 clients as they were in school. LPA interviewed Staff and Clients at this time. LPA observed 3 bedrooms and 3 bathrooms. LPA inspected and/or reviewed the following: Physical Plant License, Personal Rights and other required documentation was posted throughout the facility. Disinfectants/Cleaning Solutions are locked away in the closet area where staff have keys to access but clients do not. Pantry, Fridge, and Freezer were adequately stocked with both perishable and non-perishable food. Facility also has a back stock ready for for emergencies. Menu's were posted on the fridge with snack choices available. Hot water was tested at 110 degrees F. All fire extinguishers were filly charged.Carbon Monoxide and Smoke Detectors were observed to be in working order. First Aid Kit with back up supplies was observed. Adequate bed linens were observed in the facility. Fixtures are in adequate repair. Multiple Common Areas are available for youths to utilize. Dining area was observed to have adequate seating with furniture in good repair. All bathroom fixtures were observed to be in good repair with adequate soap and towels. Laundry Facilities are available for clientele use with a rotating schedule observed. Medication is locked in the separate room in a separate cabinet. Office is also locked with files locked in drawers for privacy. Working telephones are available in the staff office that clients have access too. Facility's motor vehicle is observed to be properly maintained with current registration and insurance. There are no external structures at this facility. (Page 1 of 3) Operations Complaint Procedures were reviewed with the Facility. All previous incidents were adequately submitted. Restraint log was reviewed. Board Minutes were made available by Facility. Disaster Preparedness Disaster & Mass Casualty Plan is updated and available throughout the facility. Monthly drills are documented for the facility. Disaster preparedness supplies were verified. Back up food storage was observed to be adequate. Emergency Intervention Staff training was documented adequately with current trainings. Restrain Log was reviewed. Staffing/Volunteers Staff Files were Reviewed. All were currently First Aid/CPR Certified through American Red Cross. Job title & qualifications were verified. All Criminal Record Clearances and Exemptions were observed. Staff either has or is currently in training. Client Records Client files were reviewed. LPA observed the Needs and Services Plans were in place with Centrally Stored Medication log, Parental Authorization for medication. Psychotropic and Medication Administration Log was was reviewed. Cash Resources Log was reviewed. Compatibility Assessment was observed. Special Health Care Needs (SHCN) SHCN plan created with staff and psychiatrist and implemented as required. Staff have received training in regards to the individual health needs of each client. The following items were reviewed for compliance in the regional office prior to the facility inspection: (Page 2 of 3) ·Annual fees · Administrator Certificate for: Cheryl Gutierrez · Emergency Disaster Plan (per H&S Code 1565) · Annual Emergency Intervention Log · Personnel Roster, Facility Sketch, LIC 500, LIC 610C and LIC 308 · Waivers and Exceptions An exit interview was conducted with Cheryl Gutierrez and a copy of this report was left with facility.

met_with: Cheryl Gutierrez- Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On March 27, 2025 at approximately 9: AM, Licensing Program Analyst (LPA),Orlando Areizaga arrived unannounced at Turning Point-Avalon for the purpose of conducting a Case Management-Other inspection to follow up on a recent Department of Developmental Services (DDS) inspection. LPA met with Cheryl Gutierrez, Facility Administrator who granted LPA access. LPA conducted a walk through of the interior and exterior of the home, and no deficiencies were noted LPA requested and reviewed the follow documents: LIC 500 and 3 staff files. LIC 500: Reviewed: names, job titles, and specific duty hours. Staff Files: CPR and First-aid up to date via approved institution Training hours Identification cards Based on a file review, LPA Areizaga did not note any deficiencies during the time of the inspection. This case management is closed and no further interview are needed at this time. Exit interview was conducted with Cheryl Gutierrez, Facility Administrator and a copy of this report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On May 21, 2025 at approximately 9: AM Licensing Program Analyst (LPA) Orlando Areizaga and Licensing Program Manager (LPM) Rosa Rodriguez made an unannounced annual inspection to the above facility. LPA and LPM met with Administrator, Cheryl Gutierrez who assisted with the inspection. LPA conducted a walk-through of the facility interior and exterior of the facility . There were 6 staff present and 0 clients as they were in school. LPA interviewed Staff and Clients at this time. LPA observed 2.5 bedrooms and 4 bathrooms. LPA inspected and/or reviewed the following: Physical Plant: License, Personal Rights and other required documentation were posted throughout the facility. Disinfectants/Cleaning Solutions are locked away in the closet area where staff have keys to access, but clients do not. Pantry, Fridge, and Freezer were adequately stocked with both perishable and non-perishable food. Facility also has a back stock ready for emergencies. Menus were posted on the fridge with snack choices available. Hot water was tested at 111 degrees F. The temperature in the facility was set at 71 degrees. All, 3, fire extinguishers were filly charged. Carbon Monoxide and Smoke Detectors were observed to be in working order. First Aid Kit with back up supplies was observed. Adequate bed linens were observed in the facility. Fixtures are in adequate repair. Multiple Common Areas are available for youths to utilize. Dining area was observed to have adequate seating with furniture in good repair. 2.5 bathrooms were observed. 1 bathroom for non- ambulatory clients, 1 bathroom for ambulatory clients, and a half bathroom. All bathroom fixtures were observed to be in good repair with adequate soap and towels. (1 of 2) Laundry services are available for clients use with a rotating schedule observed. Medication were locked in the separate room in a separate cabinet. Office is also locked with files locked in drawers for privacy. Working telephones are available in the staff office that clients have access too. Facility's motor vehicle were observed to be properly maintained with current registration and insurance. The exterior of the facility has a shed with extra storage. LPA observed overgrown landscape in the front and back yard, a leak under the kitchen sink, and a loose cupboard above the stove. Operations: Complaint Procedures were reviewed with the Facility. All previous incidents were adequately submitted. Disaster Preparedness: Disaster & Mass Casualty Plan is updated and available throughout the facility. Monthly drills are documented for the facility. Disaster preparedness supplies were verified. Back up food storage was observed to be adequate. Emergency Intervention: Staff training was documented adequately with current trainings. Staffing/Volunteers: Staff Files were reviewed. All were currently First Aid/CPR Certified through American Red Cross. Job title & qualifications were verified. All Criminal Record Clearances and Exemptions were observed. Client Records: Client files were reviewed. LPA observed the Needs and Services Plans were in place with Centrally Stored Medication log, Parental Authorization for medication. Psychotropic and Medication Administration Log were reviewed. Administrator did talk about the petty cash funds that are used for clients. Special Health Care Needs (SHCN): SHCN plan created with staff and psychiatrist and implemented as required. Staff have received training in regards to the individual health needs of each client. The following items were reviewed for compliance in the regional office prior to the facility inspection: Outstanding annual fees: $1,362.00 will be sent via Fed ex overnight to the regional office by tomorrow. Administrator Certificate for: Cheryl Gutierrez Emergency Disaster Plan (per H&S Code 1565) Annual Emergency Intervention Log Personnel Roster, Facility Sketch, LIC 500, LIC 610C and LIC 308 Technical Violations are being issues. (1) for the overgrown landscape in the front and rear of the facility. (2) for a leak under the kitchen sink and a cupboard being loose above the stove. An exit interview was conducted with Administrator, Cheryl Gutierrez and a copy of this report was left with facility. (2 of 2)


summary: Facility Evaluation

raw_content:
Narrative:
On October 22, Licensing Program Analyst (LPA) Sarina Buchannan arrived at the above Enhanced Behavioral Support Home (EBSH) for the purpose of conducting a Case Management inspection. LPA was greeted by LaVonda Sanderson, Lead RBT, who granted LPA access. LPA conducted a tour of the inside and outside of the facility where LPA observed the following deficiencies. One client bathroom does not have an operating light switch. The hinges on one cabinet door in the kitchen are not screwed in causing the door to fall off when opened. The facility provided copy of work orders for both the cabinet and the bathroom light. Work orders were placed on 10/20/2025. The facility is being issued a technical violation for Buildings and Grounds. (See LIC TV) This case management will remain open, until 11/22/2025 or until the facility provides proof it is in full compliance, whichever comes first. An exit interview conducted and a copy of this report was left with licensee.

met_with: LaVonda Sanderson, Lead RBT


summary: Facility Evaluation

raw_content:
Narrative:
On November 18, 2025, at approximately 1: PM Licensing Program Analyst (LPA) Orlando Areizaga arrived at the above Enhanced Behavioral Support Home (EBSH) for the purpose of delivering documentation. LPA was greeted by Cheryl Gutierrez, Administrator, who granted LPA access. LPA provided licensee with a copy of their updated Facility License. The new license has the age range of 7-17 years old. An exit interview conducted and a copy of this report was left with licensee.


summary: Facility Evaluation

raw_content:
Narrative:
On November 26, Licensing Program Analyst (LPA) Sarina Buchannan arrived at the above Enhanced Behavioral Support Home (EBSH) for the purpose of conducting a follow up Case Management inspection. LPA was greeted by Cheri Gutierrez, Facility Administrator, who granted LPA access. On October 22, LPA conducted a tour of the inside and outside of the facility where LPA observed the following deficiencies: One client bathroom does not have an operating light switch. The hinges on one cabinet door in the kitchen are not screwed in causing the door to fall off when opened. During today's inspection LPA observed the following: One client bathroom light to be operating properly All kitchen cabinet doors to be attached and in good repair. Two windows are shattered in the the facility dining room. LPA was able to touch windows and no shards or sharp edges are accessible due to a shatterproof window film on both windows. LPA observed work orders had been placed on 11/03/25 and 11/24/25. This case management will remain open until LPA receives proof that the windows have been repaired or by 12/27/25, whichever comes first. An exit interview conducted and a copy of this report was left with licensee.

met_with: Cheri Gutierrez, Facility Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On December 30, 2025 (LPA) Sarina Buchannan arrived at the above Enhanced Behavioral Support Home (EBSH) for the purpose of conducting a follow up Case Management inspection. LPA was greeted by Cheri Gutierrez, Facility Administrator, who granted LPA access. On November 26, 2025, LPA Buchannan observed the following: Two windows are shattered in the the facility dining room. LPA was able to touch windows and no shards or sharp edges are accessible due to a shatterproof window film on both windows. LPA observed work orders had been placed on 11/03/25 and 11/24/25. On today's inspection LPA observed the following: One window in dining room is and one window in the laundry room were shattered. LPA observed work orders had been placed on 12/16/25. LPA was informed it is a behavior for a client in care to break windows. The facility provided documentation that on each occasion work orders had been placed immediately. Since the facility is following up on damages, clients in care do not have access to any glass shards, and client in care will continue to break windows there is no additional concern for follow up. Lastly, the facility stated they will continue to place work orders and repair windows. This case Management that was initially open on 10/22/25 is now closed. No further investigation is needed. Exit interview conducted an a copy of this report was provided to licensee.

met_with: Cheri Gutierrez, Facility Administartor


raw_content:
Narrative:
Based on evidence gathered and confidential interviews conducted, the above allegations cannot be substantiated. Ten out of eleven confidential interview statements obtained stated that overnight staff do not sleep while on duty and do provide supervision. One individual stated that staff do sleep while on duty, but LPA was unable to find any additional evidence to corroborate this statement. In addition, LPA obtained and reviewed sleep logs for the months of September and October, which show that staff checked on youth every 30 minutes during overnight shifts. Also, ten out of eleven confidential interviews stated that staff do not push clients in care. One individual stated that staff pushed another client during an Emergency Intervention that required the use of protective pads to block or prevent injury; however, LPA could not obtain any corroborating evidence. No staff have any disciplinary record for misusing these pads, and lastly no other individuals interviewed reported observing clients being struck or harmed by the pads while in care. Finally, LPA was unable to verify both allegations and obtain additional information as the reporting party could not be interviewed due to them being anonymous. However, following the allegations the facility took precautions by not allowing staff named to work with client pending investigation results and conducting additional training on emergency interventions. Although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report and the Appeal Rights were discussed and provided to the licensee.

Investigation Findings:
13On December 30, Licensing Program Analyst (LPA) Sarina Buchannan made an unannounced visit to deliver findings to the above Enhanced Behavioral Support Home (EBSH) and met with Cheri Guttierez, Facility Administrator, who assisted LPA with the inspection. LPA conducted a walkthrough of the facility. Prior to the meeting, LPA Sarina Buchannan conducted the 10-day inspection of the EBSH on 10/22/2025. LPA Buchannan requested the following documents: Staff Roster (LIC 500), Client Census (LIC 9020), Client Face Sheets, staff schedule, staff contact information, incident reports regarding Client 1 (C1), sleep logs (September and October), disciplinary actions (last 2 months), and Ukeru Pad Logs (July to October). LPA Buchannan conducted a subsequent inspection on 11/26/2025 to complete additional interviews. In total, LPA attempted one and conducted eleven confidential interviews between 10/17/2025 and 12/30/2025. (report continued on LIC 9099C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Connie Goldie LICENSING EVALUATOR NAME: Sarina Buchannan LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: TURNING POINT- AVALONFACILITY NUMBER: VISIT DATE: 12/30/2025

met_with: Cheri Guttierez, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On December 30, 2025, Licensing Program Analyst (LPA) Sarina Buchannan conducted an unannounced visit to the above Enhanced Behavioral Support Home (EBSH) to initiate a Case Management Inspection. LPA Buchannan met with Cheri Gutierrez, Facility Administrator, who assisted with the inspection. LPA completed a walk through of the facility, and no deficiencies were observed. During a prior visit on October 22, 2025, LPA Buchannan obtained Ukeru Logs for a current client, C1. Upon review, LPA noted that on eight occasions between July 31, 2025, and October 09, 2025, facility staff used emergency interventions on C1 up to six times in one day. It was confirmed that C1 has a history of behaviors resulting in staff injuries, which led staff to use Ukeru pads without first attempting less restrictive de-escalation methods, such as evasion or crisis communication. Additionally, the facility failed to submit the required Incident Reports for all eight occasions when Ukeru pads were used up to six times in one day. Based on record review and interviews, it was determined that the facility did not follow its plan of operation by failing to implement the safest and least restrictive de-escalation methods while carrying out C1's emergency intervention plan. In addition, despite using this intervention up to six times on eight separate occasions, the facility did not report the necessity to use the youth's behavioral plan. As a result, the facility is being cited under Title 22, Plan of Operation and Title 22, Reporting Requirements (see LIC 809D). No further investigation is needed. This case management is now closed. A copy of this report and appeal rights were discussed and provided to licensee.