summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Page 2. Allegation #1. Staff is not keeping minors' personal information confidential. During the interview of FC1 on 4/26/23, FC1 stated that on one occasion, S1 followed them to the bus stop, and while they were trying to awol, staff told the bus driver they were from a mental hospital and not to let them on the bus because they were leaving the facility without permission. Another passenger on the bus said that FC1 should not be allowed on the bus. Staff disclosed they told the bus driver not to let FC1 on the bus because FC1 is a minor running away from the facility and the bus driver should not aid a minor to run away. FC1 was refused a ride on the bus and returned to the facility. Based on LPAs observations and interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1, Article 6, Sec. 80072, are being cited on the attached LIC 9099D. (a) Except for children's residential facilities, each child shall have personal rights which include, but are not limited to the following: (3) to be free from ...humiliation, intimidation, ridicule, coercion, threat, mental abuse. Exit interview was conducted and a copy of this report delivered to Joanna Barnhill, Assistant Administrator.

Investigation Findings:
13On 8/4/23 at 2: PM, Licensing Program Analyst, (LPA) Uchenna Ajaero made an unannounced complaint visit to the Paradise Oaks in Rosa Vista to deliver findings for this complaint. LPA met Joanna Barnhill, Assistant Administrator and informed her of the purpose of the visit. On 4/26/23, LPA Ajaero visited the facility and interviewed the Facility Manager (S1). LPA Ajaero obtained incident reports, needs and services plan for FC1, work order currently in place for carpet cleaning, case notes, CFT meeting notes for FC1. LPA also interviewed the Agency Social Worker, (ASW), S4, FC1 and FC2. On 4/28/23, LPA interviewed FC3 at school. On 5/11/23, LPA interviewed another Facility Administrator, S3. On 5/12/23, LPA interviewed the Facility Case Manager, S2. LPA interviewed Staff S6 on 5/25/23 and FC1 again on the same day. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Uchenna Ajaero 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: PARADISE OAKS - ROSA VISTAFACILITY NUMBER: VISIT DATE: 08/04/2023


state: CA

facility_name: PARADISE OAKS - ROSA VISTA

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
The child who was the alleged victim did not sufficiently detail the nature of the purported bullying by a peer. When asked and pressed, the child would not or could not provide specific examples of instances that can be reasonably characterized as bullying. The context in which the report was made was immediately after a physical altercation that resulted from a disruption in the facility by the child and the peer's response to that disruption. Both children corroborated that a direct-care staff-person was present and intervened during the incident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated. Exit interview conducted; a copy of this report and of the Appeal Rights are being provided to the facility.

Investigation Findings:
13On 10/19/ Licensing Program Analyst (LPA) Chad Cabigon conducted an unannounced inspection of this facility to deliver the findings of, and close, the complaint investigation. LPA met with Assistant Administrator Joanna Barnhill and the following report was discussed: LPA investigated a complaint alleging that Staff are not preventing minor(s) from bullying other minor while in care. The investigation was opened on 08/02/2023 via an unannounced onsite inspection of this STRTP (Short Term Residential Therapeutic Program) wherein a tour of the interior and exterior areas of the facility's physical plant was done. On the same day, interviews were also conducted with two Paradise Oaks Youth Services (POYS) staff and two youth in care. Records requested were the Needs & Services Plans (where available) for youth as well as training records for direct-care staff. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Chad Cabigon LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: PARADISE OAKS - ROSA VISTAFACILITY NUMBER: VISIT DATE: 10/19/2023

report_type: Complaint Investigation

met_with: Joanna Barnhill, Assistant Administrator

complaint_status: unsubstantiated


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
During the course of the investigation, the following documents were gathered and reviewed: Client Face Sheet, Placement Policies and Agreement(s), Incident Reports, Communication Logs, and Grievance forms for one client (FC1), and one staff file (S1); which included: background clearance documents, staff training record, employee application, staff evaluations and disciplinary notice, Communication Logs and Supervision Logs. Confidential interviews were conducted with nine individuals, and attempted with two individuals, during the period of 12/28/2023 to 04/02/2024. LPA's interviews conducted, and records reviewed were inconsistent that a facility staff sexually touched a minor while in care. Interviews conducted were inconsistent, and while statements were made pertaining to negative rapport S1 built with youth in care, no corroborating statements were made regarding an individual witnessing the alleged inappropriate or sexual touching occur between S1 and FC1. Additionally, statements made were inconsistent regarding the period of time the alleged staff member had worked at the specified facility, transported the youth, or had been in the presence of the youth for the allegations to have occurred. The staff, S1, resigned from their employment on 02/03/2024. Based on LPA interviews conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted with and a copy of this report was provided to Naeem Brown, Assistant Administrator.

Investigation Findings:
13Licensing Program Analyst (LPA) Stephannie Verna conducted an unannounced complaint inspection with the above facility on April 08, 2024 at 03: PM and met with Naeem Brown, Assistant Administrator. The purpose of the inspection was to deliver complaint findings for the above allegation. On December 28, 2023 at 11: AM Licensing Program Analyst (LPA), Stephannie Verna, arrived unannounced at the facility for the purpose of initiating a complaint investigation related to the above allegation. LPA met with Joanna Barnhill, Assistant Administrator. LPA conducted an inspection of the facility, and gathered documentation related to the complaint investigation. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Stephannie Verna LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: PARADISE OAKS - ROSA VISTAFACILITY NUMBER: VISIT DATE: 04/08/2024

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

met_with: Naeem Brown, Assistant Administrator


raw_content:
Narrative:
LPA Martinez requested the following documents for review: Client Roster, Staff Roster and Schedule, Staff Census-include New Hires/Termination Records (01/01/2025 to Present), Harm Reduction Plans (01/01/2025 to Present), Needs and Services Plans (01/01/2025 to Present), CFT notes (01/01/2025 to Present), Safety Plans (01/01/2025 to Present), bedroom door/smoking/transportation policies, house meeting notes (01/01/2025 to Present), Activity Calendar (01/01/2025 to Present), Board Meeting notes (01/01/2025 to Present). Facility staff agreed to email documents to LPA Martinez by 07/11/2025 by 5: PM. LPA Martinez conducted an inspection of the facility. An exit interview was conducted. Confidential interviews were conducted with nine individuals and one attempted during the period of July 02, 2025, to August 28, 2025. Based on interviews conducted and records reviewed, it was determined that the facility has a no smoking policy, and this policy is being implemented. Facility staff take corrective action when children violate the smoking policy on facility premises. Eight out of nine interviewees reported staff do not listen to or record youth phone calls. Additionally, LPA Martinez reviewed the facility clothing requirements and clothing price range guidelines. Clothes are purchased when need, and during the summer and winter seasons. Based on multiple interviews it was reported that there were no clothing concerns. It was also learned that transportation is being provided to children in care, and confidential interviews corroborated that transportation is being provided. In regard to activities, staff members are conducting activities, and the children in care can attend facility meetings and submit activity requests. Activities can also be conducted individually when additional staffing is available. After conducting file reviews and interviews with relevant parties, LPA Martinez determined that the facility has a bedroom open door policy. The children are able to leave their door cracked open. Additionally, record reviews and interview statements show that the facility has sufficient staff to meet the needs of the children in care. Lastly, there is not sufficient information or evidence to show that facility staff are not following their emergency intervention plan when youth leave without permission. Based on LPA Martinez's interviews conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted with Joanna Barnhill (Assistant Manager), and a copy of this report was provided to Joanna Barnhill (Assistant Manager). LPA Martinez requested the following documents for review: Client Roster, Staff Roster and Schedule, Staff Census-include New Hires/Termination Records (01/01/2025 to Present), Harm Reduction Plans (01/01/2025 to Present), Needs and Services Plans (01/01/2025 to Present), CFT notes (01/01/2025 to Present), Safety Plans (01/01/2025 to Present), bedroom door/smoking/transportation policies, house meeting notes (01/01/2025 to Present), Activity Calendar (01/01/2025 to Present), Board Meeting notes (01/01/2025 to Present). LPA Martinez conducted an inspection of the facility, and no deficiencies were observed. Confidential interviews were conducted with nine individuals and one attempted during the period of July 02, 2025, to August 28, 2025. Based on interviews conducted and records reviewed, it was determined the following allegation is substantiated: Staff are not implementing Prudent Parenting Standards. The investigation revealed that reasonable prudent parenting standards are not being applied by direct care staff. During interviews, interviewees were asked to define reasonable prudent parent standards. Based on the information collected during interviews, it was determined the interviewees did not have knowledge of reasonable prudent parent standards. Additionally, the interviewees could not recall any trainings dates pertaining to Reasonable Prudent Parent Standards. P1 reported direct care staff are not confident making prudent parent decisions and refer to management to make decisions. As a result of this investigation of this complaint, the facility will be cited under California Code of Regulations, Title 22, 87065 (d)(1) Personnel Requirements. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, are cited on the attached LIC 9099-D page. An exit interview was conducted, and a copy of this 9099 report, 9099-D Page, and a copy of the appeal rights were left at the facility with Name and Joanna Barnhill (Assistant Administrator).

Investigation Findings:
13Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced complaint inspection with the above facility on October 16, 2025, at 2: PM and met with Joanna Barnhill (Assistant Administrator). The purpose of the inspection was to deliver complaint findings for the above allegation. On July 02, 2025, at 1: PM Licensing Program Analysts (LPAs) Avelina Martinez and Angelique Hill arrived unannounced at the agency for the purpose of initiating a complaint investigation related to the above allegation. LPAs Martinez and Hill met with Amanda Lee (Administrator). SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Avelina Martinez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 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 06/24/2025 and conducted by Evaluator Avelina Martinez PUBLICCOMPLAINT CONTROL NUMBER: 23-CR- FACILITY NAME:PARADISE OAKS - ROSA VISTAFACILITY NUMBER: ADMINISTRATOR:AMANDA LEEFACILITY TYPE: ADDRESS: ROSA VISTA LANETELEPHONE: (916) 722- CITY:CITRUS HEIGHTSSTATE: CAZIP CODE: CAPACITY:6CENSUS: DATE: 10/16/ UNANNOUNCEDTIME BEGAN: 02: PM MET WITH:Joanna Barnhill (Assistant Manager)TIME COMPLETED:03: PM 9Facility does not have sufficient staff to meet the youths needs. Youth allowed to smoke on premises. Youth not allowed to shut their bedroom doors. Youth not allowed to be in their bedrooms. Staff not following the Emergency Intervention Plan when youth leave without permission. Staff refusing to transport clients. No activities that are age appropriate or can be done separately. INVESTIGATION FINDINGS: 13Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced complaint inspection with the above facility on October 16, 2025, at 2: PM and met with Joanna Barnhill (Assistant Administrator). The purpose of the inspection was to deliver complaint findings for the above allegations. On July 02, 2025, at 9: AM Licensing Program Analysts (LPA) Avelina Martinez arrived unannounced at the agency for the purpose of initiating a complaint investigation related to the above allegations. LPA Martinez met with Amanda Lee (Administrator) and Joanna Barnhill (Assistant Administrator). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Avelina Martinez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 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: PARADISE OAKS - ROSA VISTAFACILITY NUMBER: VISIT DATE: 10/16/2025

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:


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews were conducted with four individuals, during the period of September 19, 2025, to October 06, 2025. An investigation was conducted for the following allegation:" Children are not provided with sufficient hygiene care supplies." The investigation found that specialized cultural hygiene hair products were not provided to C1. On September 19, 2025, LPA Martinez conducted an inspection of the facility's hair and hygiene supplies. During this inspection, LPA Martinez learned that the facility did not have specialized cultural hygiene hair products to accommodate C1's needs. Additionally, LPA Martinez conducted a shopping file review on September 19, 2025. The shopping list document did not indicate there was a need for specialized cultural hygiene hair products. S1 also indicated they were not aware that the facility did not have specialized cultural hair care products. During the inspection, S1 ordered specialized cultural hair care products to meet C1's needs. Based on LPA Martinez's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Personal Rights: 87072 (C)(8) is being cited on the attached LIC 9099D-Page. An exit interview was conducted, and a copy of this 9099 report and appeal rights document were left at the facility with Name and Title.

Investigation Findings:
13Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced complaint inspection with the above facility on October 22, 2025, at 9: AM and met with Joanna Barnhill (Assistant Administrator) and Naeem Brown (Administrator). The purpose of the inspection was to deliver complaint findings for the above allegations. On September 19, 2025, at 9: AM, Licensing Program Analyst (LPA), Avelina Martinez, arrived unannounced at the agency for the purpose of initiating a complaint investigation related to the above allegation. LPA Martinez met with Joanna Barnhill (Assistant Administrator). During the September 19, 2023, inspection visit, LPA Martinez toured the facility with Joanna Barhill and conducted interviews. There were no concerns observed. LPA Martinez requested the following documents for child 1 (C1): Needs and Services Plan, CFTS notes/Preservation Plan, Personal Belongings and Inventory Log, Grievance forms, Safety Plans, incident reports. LPA Martinez also Continued... SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Avelina Martinez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 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: PARADISE OAKS - ROSA VISTAFACILITY NUMBER: VISIT DATE: 10/22/2025

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

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
Confidential interviews were conducted with three individuals, during the period of October 03, 2025, to October 08, 2025. An investigation was conducted for the following allegation: Staff are not following the emergency intervention plan. Two out of three confidential interviews were consistent that facility staff members were following their emergency intervention plan. One out three interviews did not provide relevant information to corroborate staff are not following the emergency plan. Based on LPA Martinez's interviews conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with Naeem Brown (Administrator), and a copy of this report was provided to Naeem Brown (Administrator).

Investigation Findings:
13Licensing Program Analyst (LPA), Avelina Martinez, conducted an unannounced complaint inspection with the above facility on October 28, 2025, at 9: AM and met with Naeem Brown (Administrator). The purpose of the inspection was to deliver the complaint findings for the above allegation. On October 03, 2025, at 9: AM, Licensing Program Analysts (LPA), Avelina Martinez, arrived unannounced at the agency for the purpose of initiating a complaint investigation related to the above allegation. LPA Martinez met with Joanna Barnhill (Assistant Administrator). During the investigation LPA Martinez obtained the following documents for review: Needs and Services Plan, CFT notes, facility notes, AWOL documentation, and runaway plan. LPA Martinez conducted interviews and conducted a tour of the facility with Joanna Barnhill (Assistant Administrator), and no deficiencies were observed. Continued... UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Avelina Martinez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 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: PARADISE OAKS - ROSA VISTAFACILITY NUMBER: VISIT DATE: 10/28/2025

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

met_with: Naeem Brown (Administrator)


summary: Facility Evaluation

raw_content:
Narrative:
On 06/18/21 at 1: PM, the second collaborative a quarterly meeting with Paradise Oaks Youth Services (POYS) was held to provide technical assistance and collaborative support to assist with and ensure POYS operates a successful program. The first meeting was held on March 19, 2020. POYS consists of nine locations: Olivine, Rosa Vista, Hazel, Hickory, Antelope, Mariposa, Old Auburn, Madison, and Sunset. The current census at all locations is 28. Two locations have closed, Linda Creek on 2/3/21 and Violets on 5/11/21. The following were present on an MS Teams virtual meeting: · CCL: Margo Castaneda, Regional Manager, Jodean Hall, Licensing Program Manager, Robin Sullivan, Licensing Program Analyst. · System of Care (SOC): Marjana Jackson, Stacie Kinney. · Sacramento County: Linda Abdelbaki · Department Health Care Services (DHCS): Brian Keefer · POYS: Robert Pye, CEO, Laynee Kuhn, Executive Director, Stephanie Fisher, Program Director, Thomas Harrer, Clinical Director POYS provided a status update of the CARF evaluation stating the accreditation approval is over two months out due to backlogs from covid. An extension of approval is in effect. The Mental Health review by Dept. of Health Care Service (DHCS) was completed in April 2021 and at this time POYS is working with DHCS in providing the plan of corrections. POYS reports numerous clients recently graduated from high school. Some graduates are enrolled in community college, some are working, some are seeking transitional housing programs, and some are still figuring things out. Distance learning challenges were reported to be with band-width issues both from the schools and at the facilities. Distance learning wa CCL reported a decrease in complaints and incident reports. POYS attribute the decline to a more deliberate intake process and screening for better compatibility with the current clients. They also reported they were revamping their level system. In addition, POYS is training house staff to participate more closely with each client and their overall treatment plan. Staff are eliciting more input from youth on what is working/not working with the program. Youth have responded with more engagement. POYS reported they are resuming a higher level of training for staff as more in-person training become available. They have contracted with Relias Learning for staff training. When asked about the status of overnight staff, POYS reported, they have two roamers that are assigned to three homes each. They also have one floater that helps out as needed or if someone calls out. This model is used both for the day shift and nighttime shift. The roamers and floaters meet regularly with staff to discuss client behaviors and needs. Sacramento County had no specific areas of concern. They complimented the discussed areas of change and the graduation of youth. DHCS discussed the pros/cons of the virtual Mental Health review and was appreciative for POYS' feedback on the process. Clarification on mask wearing requirements for POYS clients and staff will be provided as the Department receives details. POYS will submit an electronic Program Statement to include recent revisions. They next meeting is scheduled for September 17, 2021.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Executive Management


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Robin Sullivan conducted unannounced required annual inspection on 6/30/2021 at 11: PM with Carly Brown, Case Manager. The facility's status of some requirements are as follows: · Accreditation review with CARF International was conducted 4/26/21-4/28/21 and new certificate is pending. · Mental Health Contract is annual with Sacramento County. · Mental Health Program is currently in process of renewal. The facility census is three. No clients were present during the inspection. The following items were observed and evaluated by LPA Sullivan: Posted items in the facility: Facility License, Emergency Mass Casualty Disaster Plan, Foster Youth Personal Rights, Foster Youth Ombudsman, exit routes, COVID-19 handwashing instructions, and health and safety information are posted. .Kitchen- One refrigerator was tested below 45 degrees F; three freezers tested at or below zero degrees. Hot water temperature tested within the regulatory range of 105-120 degrees. Sharps are stored and locked inside the staff office. Adequate food supply including 3 days of perishable and 1 week of non-perishable items were observed. Dishwasher is operable. Adequate dishware and cooking utensils are present to meet capacity. There are no refrigerated medications. The trash can is covered. Living Area-. All window screens installed and in good condition. Seating capacity in living room and dining area accommodate all clients. Smoke & Carbon monoxide detectors are present and operable. Bedrooms- 3 of 3 client bedrooms were observed to have all had the required furnishings, including storage space. Each bed has the required mattress pad, fitted sheet, top sheet, blankets and pillow bed covering. Additional linen supplies are stored in the hall closet. Windows have screens and coverings. Smoke detectors are operable. Bathrooms- Hot water temperature tested within the regulatory range of 105-120 degrees. Toilets, sinks, and tub/showers were clean and operable. Disposable towels observed at sinks. Clients have individual personal hygiene supplies and additional hygiene items are stored in a hall closet. Buildings and Grounds- Carbon monoxide detector and smoke detector were tested and are working. Facility was clear of hazards and observed to be clean and safe. Telephone: Available and in operable condition. Cleaning & Chemical Supplies: Adequate, locked and stored in a hall closet. Doors and Passageways: Clean and free of obstructions. Facility has no bodies or water, cameras, or firearms on the premises. Facility vehicle has current registration and insurance. The tires observed to be new and all seat belts function. Exterior was clean and free of debris. Outdoor maintenance storage shed was locked and not available for inspection. Medication- Medication is stored in a locked container inside the locked staff office. Documentation of dispensing medication was reviewed. Facility has copies court or parent approval for dispensing medications. First aid kit (manual, tweezers, scissors, dressings, bandages, adhesive tape, thermometer, antiseptic solution) was available and had an adequate supply of items. Records- LPAs reviewed three of three client files. LPA Sullivan will review employee files located at the Administrative office. An exit interview was conducted and the inspection discussed with Carly Brown. Copies of documentation were provided to the facility. No Title 22 deficiencies were cited.

visit_type: Annual

met_with: Carly Brown, Case Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 09/17/21 at 1: PM, the third collaborative quarterly meeting with Paradise Oaks Youth Services (POYS) was held to provide technical assistance and collaborative support to assist with and ensure POYS operates a successful program. POYS consists of nine locations: Olivine, Rosa Vista, Hazel, Hickory, Antelope, Mariposa, Old Auburn, Madison, and Sunset. The current census at all locations is 27. Three locations: Madison, Sunset and Old Auburn currently have no foster youth placed. The following were present on an MS Teams virtual meeting: · CCL: Jodean Hall, Licensing Program Manager, Robin Sullivan, Licensing Program Analyst (LPA), Cindy Johnson, LPA, Tammy Hill, LPA · System of Care (SOC): Marjana Jackson, Stacie Kinney. · Sacramento County: Linda Abdelbaki · Department Health Care Services (DHCS): Brian Keefer · POYS: Robert Pye, CEO, Laynee Kuhn, Executive Director, Stephanie Fisher, Program Director POYS reported a staff and family moved into Sunset after their home burned down approximately 2 weeks ago. Annual inspections were completed for all their facilities in June and July, resulting in Technical Advisory/Advisory Notes and no deficiencies cited. CCL will provide the electronic program statement revisions to System of Care. Program statement revisions for the SAY population was submitted but still needs to be reviewed and approved. LPA Marla Horne will review by October 20, 2021. Incident reports regarding smoking on grounds was discussed. Both trauma-informed practices and harm reduction protocols were discussed. Harm reduction practices have not been approved by the Department. POYS is reminded that incident reports should document interventions including staff discouraging youth from smoking. CCL pointed out youth smoking in the backyard is still smoking on grounds which may require additional case management inspections. CCL requested program statement revision to Transportation services to add details of exceptions to provide transportation to youth when extreme weather, youth not feeling well or after hours. CCL requested incident reports be typed due to the difficulty of reading the handwritten reports. At this time there are multiple POYS staff that still hand write reports. This has been an ongoing conversation between POYS and CCL. CCL requests all reports be typed by November 1, 2021. POYS declined this request. CCL requested all youths' names be included in one incident report rather than referring to other involved youth as "peer". CCL recommended using a legend to submit the report to CCL and redacting the names for POYS purposes. POYS declined the request due to confidentiality. The CCL request was requested and approved through upper management and noted not to be a HIPPA violation. CCL requested incident reports and timeframes be more specific. Antecedent information is specific and thorough, yet more follow up details or resolution information is needed and requested. CCL recommended POYS to Technical Support Program (TSP) for incident report writing. POYS approved the recommendation. Sacramento County had no specific areas of concern. DHCS had no specific areas of concern. Due to the upcoming impact of FFPSA on program statements, a deadline for the revisions was not determined and will be included at the time of the FFPSA changes. No further meetings are scheduled.

met_with: Robert Pye, CEO, Laynee Kuhn, Executive Director, Stephanie Fisher, Program Director,


summary: Facility Evaluation

raw_content:
Narrative:
On 4/29/ Licensing Program Analysts (LPAs) Jean Stidman and Jessica Caplinger interviewed staff Amanda Lee, Administrator (AD) regarding an incidents dated 3/27/22 and 3/30/22 for clients C1 and C2 and an incident dated 4/1/22 for client C1.

met_with: Amanda Lee Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 9/8/22, Licensing Program Analyst (LPA) Jessica Caplinger, conducted an unannounced inspection for the purpose of conducting a case management regarding two incidents that occurred on 8/8/22 and 8/10/22. LPA met with Amanda Lee, Administrator, to discuss the incidents. LPA conducted a walk through to observe the facility inside and outside. LPA conducted four confidential interviews for this case management. No deficiencies were noted during this inspection. Exit interview was conducted with Amanda Lee, Administrator, and a final copy of this report was left at the facility.

met_with: Amanda Lee; Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 10/4/22, Licensing Program Analyst (LPA) Jessica Caplinger, conducted an unannounced inspection for the purpose of conducting a case management regarding recent incidents of substance use at the facility. LPA met with Stephanie Piring, Administrator, to discuss the incidents. LPA conducted a walk through to observe the facility inside and outside. LPA conducted three confidential interviews for this case management. No deficiencies were noted during this inspection. Exit interview was conducted with Stephanie Piring, Administrator, and a final copy of this report was left at the facility.

met_with: Stephanie Piring, Administrator


summary: Facility Evaluation

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Narrative:
On January 27, Licensing Program Manger (LPM) Dara Campos, Regional Office Manager Margo Castaneda, and Licensing Program Analyst (LPA) Stephannie Verna held an Informal Conference Meeting from 1: PM to 2: PM to discuss concerns. The meeting was facilitated by LPM Campos. Attendees included (in-person) Paradise Oaks Youth Services staff, Laynee Kuhn (Executive Director), Stephanie Fischer (Administrator), Amanda Lee (administrator) and Board Member Al Werner, as well as (Via Teams Meeting), Shawn Wade Fresno County Social Worker, Julie Leong, Case Manager Mateo County Behavioral Health, Khoa Nguyen Stanislaus County Social Worker, and Tia Carter Sacramento County Social Worker. The topics discussed included: Absent without Permission Temporary Release (TR) Communication with local law enforcement Cancelling Missing Person reports Incident Report details No deficiencies were cited during today's meeting. A copy of this report was provided to Amanda Lee, Administrator.

met_with: Amanda Lee, Administrator


summary: Facility Evaluation

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Narrative:
On March 01, 2023 at 12: PM Licensing Program Analyst (LPA) Stephannie Verna arrived unannounced at the facility for the purpose of a case management inspection. LPA Verna met with staff Hansel Owhowho. There was one staff and one client present in the facility at the time of LPA's arrival. During the review of an Incident Report received from the facility, where reportable incidents occurred on dates including 02/22/2023 and 02/24/2023, LPA Verna required additional information and a case management inspection was determined to be required. LPA Verna discussed incidents and gathered further information from staff. LPA requested, reviewed and gathered documentation pertaining to the youth involved in the incident(s). LPA completed three interviews. LPA completed a physical inspection of the facility, assisted by staff Hansel Owhowho. No citations are being issued during today's inspection. Further investigation is needed to complete the Case Management related to the Incidents and Incident Reports Received. A signed copy of this LIC-809 report was provided to the facility. An exit interview was conducted with Stephanie Piring, Floating Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On March 06, 2023 at 03: PM Licensing Program Analyst (LPA) Stephannie Verna arrived unannounced at the facility for the purpose of a case management inspection. LPA Verna met with Amanda Lee, Facility Administrator. During the review of an Incident Report received from the facility, where reportable incidents occurred on dates including 02/22/2023 and 02/24/2023, LPA Verna required additional information and a case management inspection was determined to be required. LPA Verna discussed incidents and gathered further information from Amanda Lee, Facility Administrator. LPA gathered documentation pertaining to the youth involved in the incident(s). LPA gathered additional information pertaining to staffing, Law Enforcement Contact, youth behaviors and staff interventions. LPA completed one interview. No citations are being issued during today's inspection. Further investigation is needed to complete the Case Management related to the Incidents and Incident Reports Received. A signed copy of this LIC-809 report was provided to the facility. An exit interview was conducted with Amanda Lee, Facility Administrator.

met_with: Amanda Lee, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Dung Mac conducted a case management inspection on April 5, 2023 at 10: AM based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 6 out of Direct Care Staff and 4 out of 4 youth files were reviewed. 2 out of Direct Care Staff and 2 out of 4 youth were interviewed. (See the Confidential Names List, LIC 811, April 5, 2023). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were emailed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments and Daily Communication Log, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Mac observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Administrator Amanda Lee.

met_with: Amanda Lee


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced case management inspection at the facility. LPA met with Facility Manager (FM) Ashley Rupp, and Terricka Jennings (staff) who assisted LPA with the inspection. LPA spoke with one client about a matter unrelated to this facility. An exit interview was conducted with staff and a copy of this report was sent to Administrator Amanda Lee.

met_with: Ashley Rupp


summary: Facility Evaluation

raw_content:
Narrative:
On November 20, 2023 at 10: A.M. Licensing Program Analyst Stephannie Verna arrived at the above facility and conducted an unannounced required annual facility inspection. LPA met with, Naeem Brown, Facility Assistant Administrator who assisted LPA with the inspection. LPA and the Facility Assistant Administrator conducted a joint inspection of the interior and exterior areas of the facility's physical plant. The facility is licensed for a capacity of six ambulatory clients, ages 0 to 17 years old. The census is currently three. There were two clients present at the time of the inspection. There were four staff present at the time of the inspection. The facility license and Emergency Disaster plan were posted in a locked staff office. The client Personal Rights poster and facility grievance procedure was not posted or present at the time of the inspection. The Client menu, Facility Sketch, Client Daily Activity Schedule, and a boards of resources and flyers were posted in a prominent location in the facility. The home is one story and consists of three bedrooms, two bathrooms, kitchen, dining room, living room, recreation room, a garage/storage room, staff offices and a backyard with no swimming pool or pond. There are no cameras utilized in the home or exterior cameras posted. LPA observed that the recreation room contained two couches and a chair along with a television and a shelf which contained games, books and DVDs. The recreation room contained a chair and a desk. There is an electric fireplace in the recreation room and is not used. Also, while the facility had a binder in the recreation room which stored facility grievance forms, the facility's policy regarding procedures was not posted in a location in the facility which is accessible to children and their authorized representatives. LPA observed two locked hall closets which contained extra linens, towels, and cleaning supplies. Cleaning supplies and detergents were locked in the cabinets. There were shelves located in the garage which contained storage supplies and holiday decor, hygiene supplies, soaps and hygiene products and extra food storage, including a refrigerator and freezer. continued on 809-c LPA observed that the dining area was off of the kitchen and living room and it had a table had five chairs. LPA observed that the kitchen area was located off the dining and recreation room area of the facility and that the kitchen area had a stove, oven, dishwasher, microwave and refrigerator/freezer. The light bulb in the refrigerator was missing. The kitchen contained a working landline phone. Sharps were locked in the staff office in a locked box. LPA observed some areas of the kitchen that were observed to be in need of cleaning and repair, including the kitchen drawers, kitchen flooring, baseboard and grout. The pantry was located off of the kitchen and the facility contained sufficient amounts of food in the pantry, refrigerator and freezer and fresh fruits and snacks on the counter. Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days were observed. LPA observed that the facility has three bedrooms with double-occupancy floor plan, each client in care had a bed and clean bedding provided including mattress cover, fitted sheet, top sheet and blanket, and pillows. Dressers with at least two operational drawers for personal items, lighting and ample closet or storage space was provided. Some drawers were observed to have difficulty opening smoothly and may need repair. Windows were observed to be in good repair, however window tracks were observed to contain dirt and may be in need of cleaning in multiple windows. Window screens were missing in four facility windows. LPA observed writing on multiple areas of two out of three youth bedrooms, including on a window sill, two doors, and a dresser. There were two bathrooms observed in the facility. One bathroom was located in a client bedroom, and the other bathroom was located in the hallway. The bathrooms had a working toilet, shower/tub, and sink faucet. The water temperature was measured to be at 1155 degrees Fahrenheit. The bathrooms contained soap and paper towels for hand washing. LPA observed dirt on the light switch plate; stains, dirt, and damage on the tile floor, grout, shower door and frame, sink cabinet; and the bathrooms were observed to be in need of cleaning. One light bulb was observed to be out in one of two bathrooms, and the trash can in one of two bathrooms was observed to contain solid waste, but no trash liner or lid. LPA observed a laundry area, which contained a washer and dryer, and cabinets containing extra linens. Cabinets also stored extra cleaning supplies, tools and paper products. continued on 809-c There is also a staff office, and Social Worker office, which are accessible through the kitchen. The offices contain confidential client files, and medication. Files and medications were observed to be locked. The backyard contained a large grassy area, with a bench and shed. There were no areas of damage to the surrounding fenced area. The front and back yards were free of clutter; and the passageways and egress were unobstructed. The backyard can be accessed by the two side access points on either side of the facility. LPA observed working Carbon Monoxide and smoke detectors, and they were tested and in working condition. LPA observed that there was a fire extinguisher in the kitchen and exterior/education building of the facility. The fire extinguishers were charged and last inspected in August 2023. LPA observed the first aid kit were stored in the staff office. The first aid kit was in tact, with the exception of it not including a current edition of a first aid manual and scissors. While the facility conducts emergency disaster drills quarterly, it was observed that the documentation of the drills conducted does not include the names of staff who participated in the drill and documentation of all drills conducted in the last year were not maintained at the facility. The Assistant Administrator provided LPA with documentation of the drill conducted in October 2023. LPA conducted one client interview and three staff interviews. LPA Verna completed the following domains of the inspection: Physical Plant, Operations, Core-Therapeutic Services, and Disaster Preparedness. LPA Verna began the review of the domain Client Records. The inspection was not completed on today's date and will be completed, including the following domains: Staff records, Client Records, and Emergency Interventions, on another date. The facility is being issued one citation related to deficiencies to STRTP ILS Regulations section 87072(a)(1); and Technical Advisories related to: Title Regulations, sections 80075(g)(1), 80088(e)(3), 80087(a), 80023(d)(2), and ; STRTP ILS Regulations section 87009(a); and Health and Safety Code, section 1565(c). An exit interview was conducted and a copy of this report, technical deficiencies, and LIC-809D and appeal rights was provided to Naeem Brown, Assistant Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On November 21, 2023 at 12: P.M. Licensing Program Analyst Stephannie Verna arrived at the above facility's Administrative Office, located at Sunrise Vista Dr. Suite Citrus Heights, CA 95610 and continued the unannounced required annual facility inspection. LPA met with, Alberto Muller, Recruiter/HR Assistant, who assisted LPA with the inspection of staff records. During the review of staff records, LPA Verna observed that: It was observed that one out of five (S1) staff files did not contain a current job description; The required education and experience requirements, documentation of transcripts or degree were not filed or located in the staff file (S1 and S3); During the review of annual training documentation, it was observed that documentation pertaining to required annual training for the date ranges of June 2021-2022 and June 2022-2023 was not filed and/or required annual training was not completed for one out of five staff files reviewed, (S2). Additionally, during the review of personnel files, it was observed that initial training documentation for initial minimum of 24 hours of training was documented on the "New Employment Confirmation" document in the staff files, the document did not include the exact date of completion of each initial (8 hour and 16 hour) training topic and the length of each training or training topic for all staff. LPA Verna completed the following domains of the inspection: Staff Records. The inspection was not completed on today's date and will be completed, including the following domains: Client Records, and Emergency Interventions, on another date. The facility is being issued Technical Advisories related to: Title Regulations, sections 80066(a)(8), 80066(a)(10) and 80066(a)(11) and STRTP ILS Regulations sections 87065(g)(5), 87065.1(d)(5) and 87065.1(e)(7). An exit interview was conducted and a copy of this report was provided to Alberto Muller, Recruiter/HR Assistant.

met_with: Alberto Muller, Recruiter/HR Assistant


summary: Facility Evaluation

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Narrative:
On December 01, 2023 at 09: A.M. Licensing Program Analyst (LPA) Stephannie Verna arrived at the above facility and conducted an unannounced required annual facility inspection. LPA met with, Amanda Lee, Administrator who assisted LPA with the inspection of facility records. Upon inspection of the emergency intervention log, LPA observed that the emergency intervention logs were completed as required and filed in the client files. LPA reviewed four client files and the following was observed: Upon review of medical assessment documentation, it was observed that C1 and C2 had no documentation of a completed medical assessment within 30 days of placement, including TB test and results, filed in the client file. Upon review of medical appointment forms, LPA only located dental appointment visits documented for C2. C1 has medical services assigned to an outside county, and C2's records were stated to have been lost and are being requested again from their medical provider. It was observed that all youth in care had a current Needs and Services Plan (NSP) on file for the month of November 2023, however the NSP for C2 was not updated within 30 days of the initial NSP (on 08/11/2023) and during the month of August. Additionally, multiple Needs and Services Plans were not filed in the client files for C1, C2, and C3 and verification that the NSPs were completed and updated every 30 days could not be confirmed. All other required client documentation was observed to be present and maintained in the client files at the time of inspection. LPA Verna completed the following domains of the inspection: Client Records, and Emergency Interventions. The annual inspection was finalized on today's date. The facility is being issued Technical Advisories related to: Title Regulations, section 80069(a) and STRTP ILS Regulations section 87068.3(a). An exit interview was conducted and a copy of this report was provided to Amanda Lee, Administrator.


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Avelina Martinez made an unannounced Annual Random inspection on July 09, 2025 at 9: AM. During the inspection LPA met with Amanda Lee-(Administrator) and Joanna Barhill (Assistant Administrator), and Isiah Jordan (Facility Manager) who assisted with the inspection. LPA Martinez conducted a walk-through of the facility inside and out. Facility staff-client ratio at time of inspection (two staff/ four kids present) Number of staff interviewed Two Number of clients Four LPA observed # Three bedrooms, # Two bathrooms LPA Martinez inspected and/or reviewed the following: Posting of license X Personal Rights X Disinfectants/Cleaning solutions inaccessible X Refrigerator Temperature at or below 45 degrees F X Freezer Temperature at or below 0 degrees X Nonperishable Foods one week and fresh perishable foods two days minimum X Menu present and posted X Working telephone X Carbon monoxide detectors X Smoke Detector X First Aid Kit fully stocked X Common Room available X Dining area (enough seating, furniture in good condition, not broke or damaged) In good repair Technical Violations due to three bedroom window screens not being in good repair. Work order for repair in progress. Continued... Medication centrally stored, locked/inaccessible X Office (locked and privacy) X Hot Water between 105-120 degree F (Properly labeled if over 125 degree F Fire Extinguisher (07/29/2025) Toilets wash basin, bath and shower fixtures in good repair and no leaks. Soap and Paper towels X Laundry Facilities X Bedrooms- required linen and furnishings X Motor Vehicle properly maintained , lights, tires, registration/insurance and working seat belts X Facility free of vermin X Locked Facilities (locked storage area/building/sheds) X Bedroom (required bedding/furniture, furniture in good repair) X Complaint Procedures For Youth Reviewed X Board Minutes Reviewed X CQI Report Reviewed X Disaster and mass casualty plan updated and available X Quarterly Drills conducted and documented X Disaster preparedness supplies verified X Review of manual restraint log X Staff training Pro-Act Training received. Number of Staff files reviewed Five Criminal record clearances verified Five First Aid Certificate Five Certified Administrators certificate valid and current Expired-Admin has submitted renewal documentation certificate status is pending Job title/qualification verified X Hours required training verified X Hours required annual training verified X Number of Clients files reviewed Four Needs and Services Plan X Centrally Stored Medication and log reviewed X JV Reviewed X Psychotropic Medication and log reviewed X Cash Resources X Compatible Assessment X Trauma Informed Practices are implemented as needed (including specialty mental health services and extracurricular activities and social supports) X An exit interview was conducted, and a copy of this report was provided to Joanna Barhill. No deficiencies were cited at this annual inspection. A technical violation was given for three broken window screens.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Suzanne Martinez and Licensing Program Manager (LPM) Stephen Kim conducted a case management inspection on July 22, 2025, at 8: AM based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 5 out of 7 direct care staff and 4 out of 4 youth files were reviewed. 2 out of 7 direct care staff and 2 out of 4 youths were interviewed. (See the Confidential Names List, LIC 811 (July 22, 2025). The Plan of Operation including policies and procedures were reviewed. Minutes from the Board of Directors' meetings related to the facility's incidents involving contact with law enforcement were emailed and reviewed. Based on the analysis of the confidential interviews and youth files review including the Needs and Service Assessments, Safety Plan, Risk Assessment and Treatment Plan, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Martinez observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Administrator, Amanda Lee.

met_with: Carla Izzarelli, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyss (LPAs) Misty Valencia and Aleza Ruiz on 10/30/2025 at 8:15am. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs Valencia and Ruiz met with Carla Izzarelli, Administrator and inspected the facility inside and out. LPA reviewed 1 of 3 child's records and 5//6 of staff personnel files on site at the facility. LPA reviewed 1 of 3 of child's psychotropic medications and medication records. LPA interviewed 2/6 of staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 1 of 3 children currently prescribed psychotropic medication. LPA provided a copy of this licensing report to Carla Izzarelli, Administrator. No deficiencies are being cited at this time. LPA conducted exit interview with Carla Izzarelli, Administrator.


summary: Facility Evaluation

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Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPA) Jean Stidman and Jessica Caplinger on 5/5/22 at 9:00am. During the inspection, LPAs Stidman and Caplinger met with Stephanie Piring, Administrator and inspected the facility inside and out. LPAs reviewed one child's records on site at the facility at 9:00am. During the review of one child's records, LPA Stidman observed child (C1) did not have a current copy of the court order or written authorization of the child's parent or guardian for each psychotropic medication and the Administrator and facility staff were unable to locate it. LPA Stidman observed C1 psychotropic medication logs for medications 1,2,3 and 4 (M1, M2, M3, M4) for May 2022 all have inaccurate fill dates and start dates. The facility is cited on the attached LIC 809D under the California Code of Regulations, Interim Licensing Standards #87070(b)(12) and 87070(b)(13). LPAs reviewed three staff personnel files on site at the facility at 9:00am. LPAs interviewed three staff on site at 9:00am. LPAs interviewed one child currently taking psychotropic medication at 9:00am. LPAs conducted exit interview with Stephanie Piring, Administrator at 4:30pm LPA provided the Summary Report to Stephanie Piring, Administrator upon completion. On 9/7/ LPA amended the Summary Report and provided a copy to Stephanie Piring, Administrator

met_with: Stephanie Piring Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPAs) Jessica Caplinger and Jean Stidman, conducted an unannounced inspection to the facility on 5/12/22 at 10: AM. LPA met with Amanda Lee, Administrator during the SB484 inspection on 5/5/22 when LPAs arrived at 9:00am the facility had one staff and four clients present. The facility is cited on the attached LIC 809D under the California Code of Regulations, Interim Licensing Standards 87065.5(a)(1) Direct Care/Staff Ratio. Exit interview conducted and a copy of this report and a copy of the appeal rights were left at the facility with Amanda Lee, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On April 02, 2024 at 03: PM Licensing Program Analyst (LPA) Stephannie Verna arrived unannounced at the facility for the purpose of a case management inspection. LPA Verna met with Naeem Brown, Assistant Administrator and Amanda Lee, Administrator (Via phone). During the review of an Incident Report received from the facility on 03/19/2024, where a reportable incident occurred on 03/18/2024, the facility reported a medication issue. LPA Verna reviewed documentation, discussed the incident with the Assistant Administrator and Amanda Lee, Administrator (Via phone), and gathered further information, including processes used by the facility staff, and outcomes of the incident. LPA completed interview. An inspection of the facility was completed, and no deficiencies were observed. The case management was completed on today's date. The facility is being issued one citation for a violation of Title Regulation, section 87075(c), HEALTH RELATED SERVICES. An exit interview was conducted and a signed copy of this LIC-809 report and appeal rights were provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Missed Medication Inspection was conducted by Licensing Program Analysts (LPA) Kayla Green on 6/26/2024 at 10:05AM. During the inspection, LPA Green met with Naeem Brown, Assistant Administrator and inspected the facility inside and out. During the review of an Incident Report (IR) received from the facility on 06/25/24, it was reported that on 06/22/24 a client in care (C1), Staff l checked the bubble pack and noticed on 6/22/24 there were only 4 bubbles popped out and signed for oil this day. Staff 1 checked the medication log and saw that there were no staff initials for 06/22/24 12pm, indicating the youth missed her 12pm medication that day. LPAs reviewed one child's records on site at the facility at 11:55 am. During the review of one child's records, LPA Green saw the missed initial on the medication log. The facility is receiving a Type B deficiency for the missed initial. The Administrator will provide the proof of training for the Plan of Correction by 07/26/24. LPA reviewed 2 of staff personnel files on site at the facility at 12:15PM. LPA interviewed 2 staff on site at 12:35PM. The case management inspection was completed on today's date. LPA conducted exit interview with Amanda Lee, Administrator at 12: PM, and provided the Summary Report.

met_with: Naeem Brown- Assistant Administrator


facility_name: PARADISE OAKS - SUNSET

summary: Facility Evaluation

raw_content:
Narrative:
On 06/18/21 at 1: PM, the second collaborative a quarterly meeting with Paradise Oaks Youth Services (POYS) was held to provide technical assistance and collaborative support to assist with and ensure POYS operates a successful program. The first meeting was held on March 19, 2020. POYS consists of nine locations: Olivine, Rosa Vista, Hazel, Hickory, Antelope, Mariposa, Old Auburn, Madison, and Sunset. The current census at all locations is 28. Two locations have closed, Linda Creek on 2/3/21 and Violets on 5/11/21. The following were present on an MS Teams virtual meeting: · CCL: Margo Castaneda, Regional Manager, Jodean Hall, Licensing Program Manager, Robin Sullivan, Licensing Program Analyst. · System of Care (SOC): Marjana Jackson, Stacie Kinney. · Sacramento County: Linda Abdelbaki · Department Health Care Services (DHCS): Brian Keefer · POYS: Robert Pye, CEO, Laynee Kuhn, Executive Director, Stephanie Fisher, Program Director, Thomas Harrer, Clinical Director POYS provided a status update of the CARF evaluation stating the accreditation approval is over two months out due to backlogs from covid. An extension of approval is in effect. The Mental Health review by Dept. of Health Care Service (DHCS) was completed in April 2021 and at this time POYS is working with DHCS in providing the plan of corrections. POYS reports numerous clients recently graduated from high school. Some graduates are enrolled in community college, some are working, some are seeking transitional housing programs, and some are still figuring things out. Distance learning challenges were reported to be with band-width issues both from the schools and at the facilities. Distance learning was embraced by about half of the clientele, with the other half preferring in-person learning. CCL reported a decrease in complaints and incident reports. POYS attribute the decline to a more deliberate intake process and screening for better compatibility with the current clients. They also reported they were revamping their level system. In addition, POYS is training house staff to participate more closely with each client and their overall treatment plan. Staff are eliciting more input from youth on what is working/not working with the program. Youth have responded with more engagement. POYS reported they are resuming a higher level of training for staff as more in-person training become available. They have contracted with Relias Learning for staff training. When asked about the status of overnight staff, POYS reported, they have two roamers that are assigned to three homes each. They also have one floater that helps out as needed or if someone calls out. This model is used both for the day shift and nighttime shift. The roamers and floaters meet regularly with staff to discuss client behaviors and needs. Sacramento County had no specific areas of concern. They complimented the discussed areas of change and the graduation of youth. DHCS discussed the pros/cons of the virtual Mental Health review and was appreciative for POYS' feedback on the process. Clarification on mask wearing requirements for POYS clients and staff will be provided as the Department receives details. POYS will submit an electronic Program Statement to include recent revisions. They next meeting is scheduled for September 17, 2021.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Cindy Johnson arrived at Paradise Oaks Youth Services Main Office to initiate a Required Annual on 6/23/2021 at 10: AM with Laynee Kuhn, Executive Director, due to this facility not currently having any placements. Areas discussed: annual fees, updated Administrator Certificate, waiver for 40 hours of annual staff training; and updated Emergency Disaster Plan (per H&S Code 1565). The status of other requirements was discussed, and current/updated version is being requested, for the following: · CARF International Accreditation was conducted 4/26/21-4/28/21, new certificate is pending · Mental Health Contract is renewed annually with Sacramento County · Mental Health Program approval- is currently in process of renewal and making corrections. · Emergency Intervention Log, via Board Meeting Minutes for the past 6 months, LPA Johnson followed Ms. Kuhn to POYS- Sunset and conducted the inspection. The following items were observed and evaluated by LPA Johnson: Posted items in the facility: Facility License, Emergency Mass Casualty Disaster Plan, Foster Youth Personal Rights, Foster Youth Ombudsman (other posters), exit routes, COVID-19 hand washing instructions, and health and safety information. Kitchen- a cabinet door is broken off. Five refrigerators (four downstairs) tested below 45 degrees F; one freezer tested at zero degrees. Refrigerators and freezers had various areas that needed cleaning and/or removal of old and expired food (Lactaid Milk- 2 half gallons, cream cheese, various condiments) and butter. Area to post menus is available. Hot water temperature tested within the regulatory range of 105-120 degrees (118 degrees). Knives and Sharps will be stored and locked inside the staff office. However, none are currently present. Dishwasher is operable. There are no refrigerated medications. Trash can has a lid. No disinfectants or cleaners are stored in the kitchen. Living Areas- Furniture is clean and in good repair. Smoke & Carbon monoxide detectors are present and operable. Windows have screens, but the blinds had many missing / broken slats. Carpet/flooring are in good repair. The fireplace screen that had been securely fastened and attached, now has sharp edges that can cut. The screen/blockage needs to be safely secured. Bedrooms- There are 3 client bedrooms with double occupancy; all had the required furnishings, including storage space. The facility has the required items for a bed: mattress pad, fitted sheet, top sheet, pillow and mattress in good repair, even if not on the bed; extra linen supply was present. The window in the master bedroom is missing its screen. Window coverings were adequate. Two holes are in the walls in the master bedroom. Smoke detectors are operable. There are no staff bedrooms. Cabinets in the hallway are missing handles/knobs. Bathroom- There are 2.5 client bathrooms (regular, master & half) and 1 staff bathroom. Hot water temperature tested exceeded the regulatory range of 105-120 degrees: 129, 107, 119 and 127 respectively. All client toilets need cleaning. Tub/showers were clean and operable. Buildings and Grounds- Fire extinguisher was not present. Telephone: Available and in operable condition. Carbon monoxide detector and smoke detector were tested and working. Cleaning & Chemical Supplies were not accessible. Passageways are clean and free of obstructions. Facility has no bodies or water, cameras, or firearms on the premises. Outdoor fencing has a few areas that need additional support. Agency has engaged with the neighbors for repairs. Medication- Medication is stored and locked in the filing cabinets inside the staff office, when it is present. Since no youth are currently placed, no medication or documentation were present to inspect. First aid kit was not available to be inspected. Since this facility is currently not occupied with clients and staff are not assigned to this location, file reviews and interviews were not conducted. Prior to resuming operations of this facility, the following items remain needed: Updated forms: LIC 308, 500, 610C If the administrator is changed, an updated board resolution and valid certificate. Adequate food supply- 2 days of perishable, 1 week of non-perishable and snacks Monthly menus and activity schedule need to be posted. Adequate dishware and cooking utensils. Hygiene supplies. Inspection of facility vehicle Beds have all required items No deficiencies are being cited due to no clients in placement. The agency should address all items prior to resuming the operation of the facility. Exit interview conducted and reports discussed with Laynee Kuhn, Executive Director; copies of documentation were provided to the facility, via email.

met_with: Laynee Kuhn, Executive Director


summary: Facility Evaluation

raw_content:
Narrative:
On 09/17/21 at 1: PM, the third collaborative quarterly meeting with Paradise Oaks Youth Services (POYS) was held to provide technical assistance and collaborative support to assist with and ensure POYS operates a successful program. POYS consists of nine locations: Olivine, Rosa Vista, Hazel, Hickory, Antelope, Mariposa, Old Auburn, Madison, and Sunset. The current census at all locations is 27. Three locations: Madison, Sunset and Old Auburn currently have no foster youth placed. The following were present on an MS Teams virtual meeting: · CCL: Jodean Hall, Licensing Program Manager, Robin Sullivan, Licensing Program Analyst (LPA), Cindy Johnson, LPA, Tammy Hill, LPA · System of Care (SOC): Marjana Jackson, Stacie Kinney. · Sacramento County: Linda Abdelbaki · Department Health Care Services (DHCS): Brian Keefer · POYS: Robert Pye, CEO, Laynee Kuhn, Executive Director, Stephanie Fisher, Program Director POYS reported a staff and family moved into Sunset after their home burned down approximately 2 weeks ago. Annual inspections were completed for all their facilities in June and July, resulting in Technical Advisory/Advisory Notes and no deficiencies cited. CCL will provide the electronic program statement revisions to System of Care. Program statement revisions for the SAY population was submitted but still needs to be reviewed and approved. LPA Marla Horne will review by October 20, 2021. Incident reports regarding smoking on grounds was discussed. Both trauma-informed practices and harm reduction protocols were discussed. Harm reduction practices have not been approved by the Department. POYS is reminded that incident reports should document interventions including staff discouraging youth from smoking. CCL pointed out youth smoking in the backyard is still smoking on grounds which may require additional case management inspections. CCL requested program statement revision to Transportation services to add details of exceptions to provide transportation to youth when extreme weather, youth not feeling well or after hours. CCL requested incident reports be typed due to the difficulty of reading the handwritten reports. At this time there are multiple POYS staff that still hand write reports. This has been an ongoing conversation between POYS and CCL. CCL requests all reports be typed by November 1, 2021. POYS declined this request. CCL requested all youths' names be included in one incident report rather than referring to other involved youth as "peer". CCL recommended using a legend to submit the report to CCL and redacting the names for POYS purposes. POYS declined the request due to confidentiality. The CCL request was requested and approved through upper management and noted not to be a HIPPA violation. CCL requested incident reports and timeframes be more specific. Antecedent information is specific and thorough, yet more follow up details or resolution information is needed and requested. CCL recommended POYS to Technical Support Program (TSP) for incident report writing. POYS approved the recommendation. Sacramento County had no specific areas of concern. DHCS had no specific areas of concern. Due to the upcoming impact of FFPSA on program statements, a deadline for the revisions was not determined and will be included at the time of the FFPSA changes. No further meetings are scheduled.


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Alyssa Burgess and Shawndra Miles made an unannounced annual inspection at the facility and met with a Paradise Oaks Youth Services (POYS) Administrator, Jovan Metoyer, who assisted with this inspection. After the walk-through, LPAs continued their inspection at the POYS Administration Office where we met with Stephanie Fisher, Program Director and Laynee Kuhn, Executive Director. LPAs conducted a walk-through of the facility inside and out. There were no clients present during the inspection as the facility has not been in use since 2020. There are three bedrooms, three bathrooms, a staff office, living room, den, kitchen and garage. LPA inspected and/or reviewed the following: Posting of license and Children's Personal Rights checked; Disinfectants/Cleaning solutions were found to be kept in the kitchen area of the facility. The refrigerator's temperature was read at 40 degrees Fahrenheit; the freezer temperature was at 0 degrees Fahrenheit. There was not an adequate supply of perishable and non-perishable foods as required. The only food present was purchased by the Administrator for the Administrator's personal use. There is a working landline telephone at the facility. All carbon monoxide and smoke detectors were checked with the assistance of the POYS Administrator. There was one carbon monoxide detector installed in the hallway outside of the clients' bedrooms, which was non-functional. The smoke detectors throughout the facility were working as required. There was no first aid kit at the facility. This was previously addressed with the facility on 6/30/2021, at which time they received an advisory note. An adequately sized common room was available. The dining area had enough space to accommodate clients. LPAs observed holes in the walls of the dining area and in the hallway leading to the garage. There were no medications on-site. An expired fire extinguisher was observed in the kitchen and the meter indicated it needed to be recharged. The refrigerators and freezers were not cleaned and had expired food from 2020 to Feb 2022. This was previously addressed with the facility on 6/30/2021, at which time they received an advisory note. Sinks, baths, and shower fixtures were all in good repair. The toilets were not cleaned and the water had evaporated due to limited use. Provisions of soap, paper towels, and other personal hygiene were observed in the master bathroom only. The laundry area was clean; required linen and furnishings were found to be present and in working order in the linen closets. There were no facility service vehicles on-site. There was no indication of the facility campus having any pest infestation. The facility was unclean and in disrepair in several parts: surfaces, doors, walls, and carpets were dirty with smears, crumbs, etc. there were holes in the wall in the bathroom near the garage/kitchen, broken moulding and no door on the hallway closet, a missing light bulb in one bathroom, garbage on counter in kitchen, dirty dishes in sink, general clutter and debris throughout whole house. Administrator's bedroom messy, piles of dirty linens/towels in the garage. Staff office had a foul odor. The facility has a Disaster and Mass Casualty plan that is up-to-date and readily available. LPAs instructed the facility to amend the plan to indicate how refrigerated medication will be stored. Currently, the facility is not conducting drills, as there are no clients. LPA's observed an POYS Administrator residing at the facility. During the course of the inspection the Administrator admitted to having a firearm with a loaded magazine and ammunition improperly stored on the premises. The firearm was in a locked box, which the Administrator unlocked for LPAs to show an unloaded firearm, with two magazines next to it, one of which was loaded. The Administrator also had two boxes of additional ammunition, which was kept unlocked, in a bag. LPA let Administrator know those cannot be stored in that manner, and how to store them properly. Administrator removed the ammunition from the magazine and took all ammunition to his car to be secured. Additionally, there was curved knife that was in the Administrator's bedroom, which he stated was confiscated from a client. The Administrator's room smelled of marijuana, showed presence of marijuana, and smoking paraphrenia, to which the Administrator admitted to owning. There were various other things missing or incorrect, which LPA detailed in the attached Technical Violation Advisory Notes, which are not citations: 80076(a)(17,19-20), 80088(e)(3), Interim Licensing Standards 87076(c)(4), Health & Safety Code 1565(a)(7)(e). On this date, the facility is being cited for violations of the California Code of Regulations (CCR), Title 22, Division 6, Sections: 80087(d), 80087(g)(3), 80087(a),80087(c), 80076(a)(18), 87076(c)(1), 80075(g), 80088(c). An exit interview was conducted with the Administrator and a copy of this report was emailed to her with appeal rights and read receipt which will serve as the record of receipt.

Deficiencies:
80088(c): Deficient Practice Statement
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4Based on observation, the licensee did not comply with the section cited above when the protective screen of both fireplaces were in disrepair.
80075(g): Deficient Practice Statement
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4Based on observation, the licensee did not comply with the section cited above when there was no First Aid Kit on the premises.

met_with: Jovan Metoyer, Administraor; Stephanie

title:
Fixtures, Furniture, Equipment and Supplies

(c) Fireplaces and open-faced heaters shall be inaccessible to clients to ensure protection of the clients' safety.

This requirement is not met as evidenced by

title:
(g) If the facility has no medical unit on the grounds, first aid supplies shall be maintained and be readily available in a central location in the facility.

This requirement is not met as evidenced by


summary: Facility Evaluation

raw_content:
Narrative:
On January 27, Licensing Program Manger (LPM) Dara Campos, Regional Office Manager Margo Castaneda, and Licensing Program Analyst (LPA) Stephannie Verna held an Informal Conference Meeting from 1: PM to 2: PM to discuss concerns. The meeting was facilitated by LPM Campos. Attendees included (in-person) Paradise Oaks Youth Services staff, Laynee Kuhn (Executive Director), Stephanie Fischer (Administrator), Amanda Lee (administrator) and Board Member Al Werner, as well as (Via Teams Meeting), Shawn Wade Fresno County Social Worker, Julie Leong, Case Manager Mateo County Behavioral Health, Khoa Nguyen Stanislaus County Social Worker, and Tia Carter Sacramento County Social Worker. The topics discussed included: Absent without Permission Temporary Release (TR) Communication with local law enforcement Cancelling Missing Person reports Incident Report details No deficiencies were cited during today's meeting. A copy of this report was provided to Laynee Kuhn, Executive Director.


facility_name: PEACOCK ACRES

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

raw_content:
Narrative:
On 03/16/2021 and 06/07/ LPA Segura observed that the facility has a defunct intercom system installed in the home. What appears to be the main control in the kitchen; has a faceplate that is no longer secure to the wall and falls down onto the counter. LPA Segura was able to use their state issued iphone to capture photos of the intercom. During todays inspection the facility repairman used a sensor to show that there were live wires in the wall of this intercom; although they were capped with plastic electrical caps. Further inspection of the home on 03/16/2021 and 06/07/2021, LPA Segura observed there were multiple faceplates missing from electrical and phone outlets in the home. LPA was able to use their state issued iphone to capture pictures of the missing faceplates. Some of the faceplates appear to be missing in areas the facility has had to patch the walls due to residents damaging the walls and outlets. On todays date, 06/07/ LPA observed that the living room sliding door windows are in need of repairs. The part of the sliding doors that is are not meant to slide have been pushed away from the wall creating a half inch opening to the outside. Further one of the sliding doors has come off the rail creating a half inch opening to the outside. Both items have allowed cold air and insects to come into the home. Based on observation and photographic evidence obtained, there is a preponderance of the evidence to prove that the facility is in need of repair and deep cleaning. Therefore, the above allegations are substantiated. Appeal Rights were provided and discussed with the Andrew Sandoval and deficiencies were cited. Exit interview conducted and a copy of the report was left Andrew Sandoval.

Investigation Findings:
13The purpose of the inspection was to deliver the findings for the above complaint allegations. On March 11, 2021, The department recevied a complaint regarding the cleanliness and good repair of the facility. Based physical evidence, observed on March 16, 2021 and June 7, 2021 it was determined that the facility is in disrepeair and in need of deep cleaning. On 03/16/2021 at 10:30am LPA Segura observed the facility garage had excrement and urine of the facility pert dog. Once in the home LPA observed that the walls and baseboards throughout the home are in need of deep cleaning as they were observed to have buildup of liquid spills, dust and dirt. On todays date 06/07/ LPA Segura observed that the garage is clean and did not observe any urine or feces; however, the inside is still in need of deep cleaning of surfaces, walls and baseboards. LPA was able to take pictures of the items in need of cleaning on 03/16 and 06/07. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Joel Segura 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 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: PEACOCK ACRESFACILITY NUMBER: 270702624

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

Deficiencies:
00871: Based on photo evidence and observation of the1
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met_with: Andrew Sandoval

title:
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7(a)	The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement is not met as evidenced by


summary: Complaint Investigation - Substantiated - 1 deficiency

raw_content:
Narrative:
On 06/07/ LPA Segura observed that the facility has a defunct intercom system installed in the home. What appears to be the main control in the kitchen; has a faceplate that is no longer secure to the wall and falls down onto the counter. LPA Segura was able to use their state issued iphone to capture photos of the intercom. During todays inspection the facility repairman used a sensor to show that there were live wires in the wall of this intercom; although they were capped with plastic electrical caps. Further inspection of the home; LPA Segura observed there were multiple faceplates missing from electrical and phone outlets in the home. LPA was able to use their state issued iphone to capture pictures of the missing faceplates. Some of the faceplates appear to be missing in areas the facility has had to patch the walls due to residents damaging the walls and outlets. On todays date, 06/07/ LPA observed that the living room sliding door windows are in need of repairs. The part of the sliding doors that is are not meant to slide have been pushed away from the wall creating a half inch opening to the outside. Further one of the sliding doors has come off the rail creating a half inch opening to the outside. Both items have allowed cold air and insects to come into the home. Based on observation and photographic evidence obtained, there is a preponderance of the evidence to prove that the facility is in need of repair and deep cleaning. Therefore, the above allegations are substantiated. Appeal Rights were provided and discussed with the Andrew Sandoval and deficiencies were cited. Exit interview conducted and a copy of the report was left Andrew Sandoval.

Investigation Findings:
13The purpose of the inspection was to deliver the findings for the above complaint allegations. On June 1, 2021, the department recevied a complaint regarding the good repair of the facility. Based physical evidence, observed on June 7, 2021 it was determined that the facility is in disrepeair and in need of deep cleaning. In the course of inspecting the home, LPA observed that the walls and baseboards throughout the home are in need of deep cleaning as they were observed to have buildup of liquid spills, dust and dirt. LPA was able to take pictures of the items in need of cleaning 06/07. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Joel Segura 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 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: PEACOCK ACRESFACILITY NUMBER: 270702624

Deficiencies:
00871: Based on photo evidence and observation of the1
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3
4
5
6
7

met_with: Andrew Sondoval


raw_content:
Narrative:
Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that there is vermin in the home. The client and staff have not reported seeing them in the home. Appeal Rights were provided and discussed with Andrew Sandoval. No deficiencies were cited. Exit interview conducted and a copy of the report was left with the Andrew Sandoval.

Investigation Findings:
13The purpose of the inspection was to deliver the findings for the above complaint allegations. On June 3, 2021, the department recevied a complaint regarding there being vermin in the home. Based physical evidence, interview of C1, and observation on June 7, 2021 it was determined that the facility may have vermin. (C1, Client 1, see confidential name list LIC 811 dated 06/07/2021). In the course of inspecting the home, LPA did not observe any evidence of there being vermin in the home. C1 stated that they have never seen any vermin in the home, rather they have heard them in the attick. The facility provided a bill showing there is monthly pest control service to the home. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Joel Segura 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 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: PEACOCK ACRESFACILITY NUMBER: VISIT DATE: 06/07/2021


raw_content:
Narrative:
Interviews conducted with S5, S7 and S8 revealed that they had been trained and participate in annual refresher courses. Trainer S7 stated that he conducts regular training to for staff specifically for the nonviolent crisis interventions, other training's are conducted by the facility manager or self-paced online training by outside providers. The interview with S7 revealed that the runaway training is not part of the Nonviolent Crisis Intervention (NCI) and Emergency Intervention Plan training. Eric stated that the NCI training only touches on runaways when a hold is necessary not prevention. Eric indicated that due to personal rights the facility mostly tries to talk children out of running away and only ever conduct a hold on a child if they are being a danger to themselves or others such as attempting to run into traffic. Interviews conducted with staff revealed that staff felt as if they could not do anything to prevent a child from running away; however, did admit that they attempt to talk children out of running away by following them when they attempt to walk away and conduct bed checks overnight to ensure they are still in bed. Staff also report calling non-emergency number for the Monterey Sheriff's office to report a missing child. A review of the facility Program Statement revealed that although the facility does have a Runaway Plan, there is no indication that facility staff are trained in the plan. LPA Segura reviewed at hire training list and new hire training checklists for five staff. None of the documents showed that the facility is training staff on the runaway plan. An interview conducted with S8 confirmed that although staff knows some of the steps of the runaway plan, they had not seen the plan before LPA showed them a copy on 09/17. A brief review was conducted with administrator Andrew Sandoval of the facility training documents and confirmed that the Runaway Plan is not listed on any of the checklists or training materials. Based on observation and photographic evidence obtained, there is a preponderance of the evidence to prove that the facility staff were not trained in the agency Runaway Plan. Therefore, the above allegations are substantiated. Appeal Rights were provided and discussed with the Andrew Sandoval and deficiencies were cited. Exit interview conducted and a copy of the report was left Andrew Sandoval.

Investigation Findings:
13The purpose of the inspection was to deliver the findings for the above complaint allegations. LPA Segura met with administrator Anrew Sandoval. On March 11, 2021, The department received a complaint regarding untrained staff. LPA Segura interviewed staff S4 on 04/07/21 at 4:15pm, S5 on 08/25/21 at 10:15am, S6 on 08/20/21 at 10am, S7 on 09/01 at 4:15pm, S8 and S2 on 09/17 at 11:00am. See confidential names list LIC 811 dated 09/21/ LPA Segura obtained staff training records at the facility on 08/25/2021 at approximately 10am. Five staff training documents were reviewed for new hire training. LPA Segura observed that all five staff had evidence that they were trained in accordance with the facilities training plan including Non violent Crisis Intervention and Emergency Intervention Plan. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Joel Segura 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 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: PEACOCK ACRESFACILITY NUMBER: VISIT DATE: 09/21/2021

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

Deficiencies:
87076.11: Based on staff interviews and records review the1
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7Plan of Correction due 09/22/21.

title:
2
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7(C)(3)(C) Facility's policies and procedures, including reporting requirements to the Department and as a mandated reporter; This requirement is not met as evidences by


raw_content:
Narrative:
RP further indicated that this occurred due to the food meant for the meal had been consumed prior to the menu planned day. LPA Segura conducted an interview with staff S8 (Staff 8, see confidential names list LIC 811 dated 09/21/21) on 09/17 at approximately 11am and S2 on 09/14 at approximately 12:30pm. Interview with S8 confirmed that there are times when clients want to eat a meal prior to the planned date on the menu and they have to improvise if the ingredients are used prior to the planned meal day. S8 denied that there were times that there was not enough food. S8 stated that there is always sufficient food. Interview with S2 revealed that the facility staff do attempt to stick to the posted menu; however, clients sometimes want something different or want the meal sooner than posted. S2 indicated that in those cases staff have to choose a different meal to provide clients. S2 stated that if they are missing ingredients or were used up, the staff calls the office to request the items be brought to the home. Interview was conducted with C1 (Client 1, see confidential names list LIC 811 dated 09/21/21) on 09/17/2021 at 12:30 pm. C1 stated denied there was insufficient food in the home. An interview was conducted with C2 on 09/14/21 at 1:20 pm. C2 indicated that they had sufficient food and had no complaints to report about food. On 09/ LPA Segura conducted an inspection of the facility menu and confirmed that the facility had the ingredients necessary to cook meals listed on the Menu. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that there was insufficient food service in the home; therefore, the above allegations are unsubstantiated. Appeal Rights were provided and discussed with Shaniz Beza. No deficiencies were cited. Exit interview conducted and a copy of the report was left with Shaniz Beza.

Investigation Findings:
13Licensing Program Analyst (LPA) Joel Segura conducted a follow-up complaint investigation to the STRTP (Short Term Residential Therapeutic Program) and met with Shaniz Beza. The purpose of the inspection was to deliver the findings for the above complaint allegation. On March 11, 2021, an anonymous reporting party (RP), reported to the department that the facility failed to provide adequate food service to clients in care. The RP reported that the facility does not follow the menu and often does not have enough food. An interview conducted by LPA Segura with RP on 08/18 at 3pm confirmed the reported information that the facility does not follow the posted menu. RP also indicated that although there were times when the menu item was not available, the facility had food to cook for clients in care. Continued on 9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Joel Segura 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 26-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. First Street, Ste. FACILITY NAME: PEACOCK ACRESFACILITY NUMBER: VISIT DATE: 09/24/2021

met_with: Shaniz Beza