facility_name: BORN FOR NIA MATERNITY HOME

raw_content:
Narrative:
It was stated that the facility provides childcare to clients that attend school, work or have emergency situations. It was stated that no childcare is provided for clients after 10pm daily at the facility. During the investigation LPA Rogers learned from written reports that C1 left the facility after 10pm. It was reported that during her absence from the facility, C1 left her minor child unattended in the facility. C1 did not return to the facility until 5:30 am the next morning to minor child crying. It was at that time staff informed C1 the minor child was left unattended and crying for hours at the facility. It was reported to LPA during interviews that C1 was never denied childcare but that C1 only prefers specific staff to care for her child during her absence which limits the availability for childcare. Community Care Licensing also received an allegation that a minor is not being provided safe and comfortable accommodations while in care. It was alleged that staff told C1 to leave minor child unattended laying on facility couch. It was also alleged that C1 minor child developed diaper rash due to facility staff not being attentive to minors needs. It was reported during interviews that C1 leaves the minor child unattended in a swing during the night. It was also reported that facility staff has had several conversations with C1 regarding it not being safe nor comfortable leaving the minor child in the swing unattended for hours. It was stated that each time there is a conversation regarding C1 behaviors, C1 will become loud and argumentative with staff and accuse staff of complaining. It was also reported that there have been no complaints or requests for medical attention for minor children with diaper rash in the facility. During her absence away from the facility the minor child was not fed nor was the minor child's diaper changed or needs attended to. There were never any complaints regarding a minor developing a diaper rash or a minor's diaper not being changed due to childcare staff not being attentive to the child's needs. Based on interviews and written documentation, the allegation that staff failed to provide child care for C1 minor child and staff failed to provide safe and comfortable accommodation for C1's minor child which resulted in minor child developing diaper rash, may have occurred, however, is not supported by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted and a copy of this report, LIC 811, and appeal rights were given to Virgie Allen, Facility Manager.

Investigation Findings:
13On Thursday, December 2, 2021 at 4:00 pm, LPA Rogers made contact with Born for Nia Facility Manager Virgie Allen to discuss the investigative finding of the allegation listed above. On July 8, 2021 at 9:40 am, LPA Rogers conducted a safety inspection of the facility. No deficiencies were observed. During the course of the investigation, LPA Rogers interviewed Executive Assistant, Staff (S1-S3) and Clients (C1-C4). The following documents were obtained from the facility: Placement Agreements (C1-C4), Facility Sketch, Client Roster, Staff Roster, Copy of Facility Incident Reports and Special Incident Report (SIR). On July 2, 2021, the Department received a complaint stating that facility failed to provide appropriate care and supervision to a minor while in care. It was alleged staff refused to provide childcare for C1 minor child. It was reported during confidential interviews that the facility does provide childcare for clients with minor children. It was also reported during confidential interviews that staff provides good and safe childcare for minor children of the clients. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Christina Barnes LICENSING EVALUATOR NAME: Latricia Rogers 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 19-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, MAIN ST., SUITE FACILITY NAME: BORN FOR NIA MATERNITY HOMEFACILITY NUMBER: VISIT DATE: 12/02/2021

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

met_with: Virgie Allen- Facility Manager


state: CA

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Investigation Findings:
13On November 10, 2021 at 10:30am, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced inspection to the facility to deliver the findings of the above allegation. LPA met with Devonda Blackmon. LPA Latricia Rogers conducted an inspection of the facility on December 23, 2021 at 1:30 pm and no immediate deficiencies were observed. Four staff, five of five clients (C1, C2, C3, C4, C5), county social worker and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that C1 was threatened by C2. Confidential staff interviews reported that C1 was asleep and when C1 awoke another client (unknown name), told C1 that C2 had threatened C1. Confidential interviews reported that no staff had overheard C2 make a threat or talk about C1. Other confidential information received stated that the allegation was true. The interviews that were provided to the LPA were not consistent regarding the allegation of lack of supervision resulting in C1 being threatened by C2. Based on interviews and record reviews the allegation that C1 was threatened by C2, may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Devonda Blackmon. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

report_type: Complaint Investigation

met_with: Devonda Blackmon

complaint_status: unsubstantiated


raw_content:
Investigation Findings:
13On February 28, 2023 at 1:47 pm, Licensing Program Analyst's (LPA's) Darlene Almaraz-Oseguera and Emina Preciado conducted an unannounced inspection to the facility to deliver the findings of the above allegations. LPA met with Devonda Blackmon. LPA Linda Haynes conducted an inspection of the facility on March 09, 2022 at 12:45 pm and no immediate deficiencies were observed. Three of four clients (C1, C2, C3, C4), four staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that due to lack of supervision C1 is absent without leave (AWOL) from the facility. Confidential staff interviews reported that staff verbal counsel all of the clients including C1 prior to AWOLing. Confidential staff interviews reported that staff will physically follow the clients until staff loses sight of them. The interviews that were provided to the LPA were not consistent and did not provide any specific details regarding lack of supervision. Based on interviews and record reviews the allegation that RP hit C1 as a form of discipline, may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Devonda Blackmon. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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


raw_content:
Narrative:
Based on confidential interviews and observation, the allegation that the facility does not have enough food for minors in care may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted. A copy of this report, LIC 811, and appeal rights were explained and given to Administrator, Devonda Blackmond..

Investigation Findings:
13On March 14, 2023, at 11: AM, Licensing Program Analyst (LPA) Leslie Covarrubias met with Administrator Devonda Blackmond to deliver the findings for the above-stated allegation. On 09/16/2022 at 9: AM, LPA Covarrubias inspected the physical plant and observed no immediate health and safety hazards. The investigation included an interview with Client (C3), County Social Workers, and Administrator. Clients (C1-C2) were unable to be interviewed due to C1's whereabouts being unknown and C2 refusing to be interviewed. The Department received an allegation on March 9, 2022, that the facility does not have enough food for minors in care. Confidential interviews disclosed that the facility sometimes followed the food menu, and there was an issue of insufficient food a few times. Other confidential interviews indicated there is always sufficient food and snacks. LPA Covarrubias also observed enough food and items on the facility menu during the inspection on 09/16/2022. During the inspection, LPA observed two days of perishable food, seven days of non-perishable food, and various snacks. (Continue on next page...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Leslie Y Covarrubias 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 19-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, MAIN ST., SUITE FACILITY NAME: BORN FOR NIA MATERNITY HOMEFACILITY NUMBER: VISIT DATE: 03/14/2023

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

met_with: Administrator, Devonda Blackmond


raw_content:
Narrative:
The Department also received an allegation that staff does not conduct meetings with the responsible party (County Social Worker). Confidential interviews revealed that the facility did not provide Child and Family Team (CFT) meeting notes to the County Social Worker. Other confidential interviews reveled that CFT meetings were being held and facilitated by the facility. Record review revealed that CFT meeting notes for C1 were sent to the County Social Worker. The Department also received an allegation that staff does not report incidents to the responsible party (County Social Worker). Confidential interviews revealed that the facility provided verbal incident reports, however, did not provide written incident reports to authorized representatives. Other confidential interviews revealed the facility reported incident reports via email. Record review revealed that C1's incident report dated 03/20/2022 was sent to the incorrect County Social Worker. Based on inconsistent confidential interviews and information obtained, the allegations that staff do not provide the responsible party with a copy of the minor's records, staff do not conduct a meeting with the responsible party, and the staff does not report incidents to the responsible party may have occurred, however, is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted. A copy of this report, LIC 811, and appeal rights were explained and given to Administrator, Devonda Blackmond.

Investigation Findings:
13On March 14, 2023, at 10: AM, Licensing Program Analyst (LPA) Leslie Covarrubias met with Administrator Devonda Blackmond to deliver the findings for the above-stated allegations. On 03/17/2022 at 2: PM, LPA Latricia Rogers inspected the physical plant and observed no immediate health and safety hazards. The investigation included an interview with Client (C1), County Social Workers, and Executive Assistant. Clients who were unavailable for an interview were Client 2 (C2) whereabouts were unknown, and Client 3 (C3) refused to be interviewed. The Department received an allegation on March 9, 2022, that staff do not provide the responsible party (County Social Worker) with a copy of the minor's (C1's) records. Confidential interviews indicated the facility would not forward any documentation regarding Needs and Services Plans (NSP) and Child and Family Team (CFT) meeting notes to the appropriate authorized representative. Additional confidential interviews revealed that the facility had a different Administrator at the time. There were many pertinent document issues during that period, such as the CFT and NSP for C1. Record review and confidential interviews revealed that CFT meeting notes and NSPs for C1 were sent to the County Social Worker via email. (Continue on next page..) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Leslie Y Covarrubias 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 19-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, MAIN ST., SUITE FACILITY NAME: BORN FOR NIA MATERNITY HOMEFACILITY NUMBER: VISIT DATE: 03/14/2023

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


raw_content:
Narrative:
Record review and confidential interviews corroborated that $2,700 was returned to C1 as a cashier's check once the facility realized it was for C1. There are corroborated statements and records that the facility mishandled the resident's payment, however, the facility gave back the total amount of $2,700 to C1, which was the original amount sent to the facility address for C1. Based on confidential interviews and record review, the allegation that the facility mishandled the resident's (C1) payment may have occurred, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted. A copy of this report, LIC 811, and appeal rights were explained and given to Executive Assistant Vanessa Maddox.

Investigation Findings:
13On March 24, 2023, at 9: AM, Licensing Program Analyst (LPA) Leslie Covarrubias met with Executive Assistant, Vanessa Maddox to deliver the findings for the above-stated allegation. On 08/29/2022 at 10: AM, LPA Covarrubias inspected the physical plant and observed no immediate health and safety hazards. The investigation included interviewing Clients (C1- C3), the Administrator, and County Social Worker. LPA obtained pertinent documents, such as copies of the original check sent to C1, written in C1's name, and the cashier's check from the facility/corporate bank account to C1. The Department received an allegation on August 23, 2022, that facility mishandled the resident's (C1) payment. Confidential interviews and record reviews revealed that C1 had received an expectant parent payment check for $2,700.00 addressed to C1 that the facility cashed. Confidential interviews also revealed that this was the first expectant payment received, and the check was thought to be for the facility. Additional confidential interviews revealed that C1 was issued a cashier check for $2,700.00 on August 19, 2022. (Continue on next page...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Leslie Y Covarrubias 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 19-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, MAIN ST., SUITE FACILITY NAME: BORN FOR NIA MATERNITY HOMEFACILITY NUMBER: VISIT DATE: 03/24/2023

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

met_with: Executive Assistant Vanessa Maddox


raw_content:
Narrative:
Additional confidential interviews reported that staff conducts bedroom checks every 30 minutes to ensure the safety of the clients and to prevent clients from stealing personal belongings from each other. Confidential interviews revealed that staff S1 did provide C1 with the inventorying item sheet, however, C1 never returned the sheet, and C1 refused to fill out the inventory sheet. Confidential interviews indicated that staff gives the inventory sheet to all clients for them to fill out. Confidential interviews revealed that the facility addressed the issue of inventorying clients' personal belongings during the Child and Family Team Meeting held on 01/24/2023. Based on inconsistent interviews and being unable to interview some of the clients, the allegations that staff did not safeguard residents (C1) personal belongings and staff is not inventorying residents (C1) items, may have occurred, however, is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted. A copy of this report, LIC 811, and appeal rights were explained and given to Executive Assistant Vanessa Maddox.

Investigation Findings:
13***This is an amended report of the report delivered on March 24, 2023*** Report was not originally marked Public. On March 24, 2023, at 10: AM, Licensing Program Analyst (LPA) Leslie Covarrubias met with Executive Assistant, Vanessa Maddox to deliver the findings for the above-stated allegations. On 08/29/2022 at 10: AM, LPA Covarrubias inspected the physical plant and observed no immediate health and safety hazards. The investigation included interviews with the Client (C2), the Administrator, and County Social Workers. Clients (C1 and C3) left the facility without permission and were unable to be located and, therefore, unable to be interviewed. On January 26, 2023, the Department received allegations that staff (S1) did not safeguard residents' (C1) personal belongings and that staff (S1) was not inventorying residents (C1) items. Confidential interviews indicated that C1 and C2 entered each other's rooms and stole clothes. Confidential interviews disclosed that staff notified clients not to enter another client's room. (Continue on next page...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Leslie Y Covarrubias 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 19-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, MAIN ST., SUITE FACILITY NAME: BORN FOR NIA MATERNITY HOMEFACILITY NUMBER: VISIT DATE: 03/24/2023

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


raw_content:
Narrative:
The Department also received an allegation that staff does not report children's AWOLs to Community Care Licensing (CCL). During the investigation, S1 provided LPA with Special Incident Reports (SIRs) for C AWOLs on dates 06/07/2022, 06/06/2022, 06/11/2022, and 6/19/2022. Confidential interviews revealed that C4 would constantly be AWOL from the facility. Other confidential interviews revealed no incidents occurring in June 2022 of clients leaving the facility without permission. Additional confidential interviews reported that staff would notify clients' authorized representatives of any clients leaving without permission, and an incident report would be submitted to CCL and the County. The facility could not locate the emails sent to CCL regarding the SIRs being submitted, even though the staff provided the SIRs for the days C4 left the facility without permission. The Department also received an allegation that children smoke marijuana on the premises. Confidential interviews revealed that when contraband is found, it is confiscated, and a SIR is submitted. Other confidential interviews revealed that clients are prohibited from smoking, and no clients have been observed smoking in the facility. Based on inconsistent confidential interviews and observation, the allegations that staff left children alone at facility, staff do not report children AWOLs to CCL, and children smoke marijuana on the premises, may have occurred, however, is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted. A copy of this report along with LIC 811 and appeal rights were discussed and handed to Administrator, Devonda Blackmond.

Investigation Findings:
13On March 28, 2023, at 10: AM, Licensing Program Analyst (LPA) Leslie Covarrubias met with Administrator Devonda Blackmond to deliver the findings for the above-stated allegations. On 06/23/2022 at 4: PM, LPA Covarrubias inspected the physical plant and observed no immediate health and safety hazards. LPA obtained pertinent documents such as Special Incident Report (SIRs), and staff timesheets. The investigation included interviewing Clients (C1- C3), the Administrator, and County Social Worker. Client 4 (C4) was unable to be interviewed due to C4's whereabouts being unknown. The Department received an allegation on June 21, 2022, that staff left children alone at the facility. Confidential interviews revealed that staff left the clients alone on more than one occasion. Confidential interviews revealed that all clients had been left alone. Other confidential interviews revealed that clients have always been supervised, and at least one staff member is always on the premises. During the inspection and record review on June 23, 2022, LPA Covarrubias observed the facility to be in compliance with Interim Licensing Standards regarding the staff/client ratio. (Continue on next page...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Leslie Y Covarrubias 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 19-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, MAIN ST., SUITE FACILITY NAME: BORN FOR NIA MATERNITY HOMEFACILITY NUMBER: VISIT DATE: 03/28/2023

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

met_with: Adminstrator, Devonda Blackmond


raw_content:
Narrative:
On February 3, 2021, the Department received a complaint stating that facility staff did not prevent C1 from AWOLing. It was reported during confidential interviews that C1 was not comfortable at the facility and staff were constantly being rude is what led C1 to continually AWOL. It was disclosed during confidential interviews that C1 would be given a community pass, leave the facility with no adult supervision and would not return to the facility before curfew. It was reported that there were no consequences given to clients when AWOLing from the facility. It was explained to LPA Rogers that community passes from the facility were for all day with a curfew time of 10:00 pm. It was also reported during interviews that clients were allowed 20 - 30 minute walks 2 times per day from the facility. These walks would give opportunities for clients to leave and not return to the facility. LPA Rogers learned during confidential interviews that because of low staffing clients are encouraged to take a day pass or be transported to the Moreno Valley facility during the hours of 4:00 pm and 10:00 pm, which also contributed to clients AWOLing from the facility. It was reported that community passes are privileges given to clients by their CSW. It was also reported that an AWOLed client is not reported until 2 hours past reporting time. It was also reported that staff would try to verbally deter, counsel and inform clients of the consequences of AWOLing from the facility. CSW disclosed during interviews that clients were constantly AWOLing from the facility but had not received complaints of having to leave the facility during certain hours because of low staffing. CSW also stated that the facility follows the rules regarding client's AWOLs and is notified each time a client AWOLs with daily updates from the facility. Based on interviews, the allegation that staff did not prevent C1 from AWOLing, may have occurred, however, is not supported by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted and a copy of this report, LIC 811, and appeal rights were given to Winifred Hall, Facility Manager.

Investigation Findings:
13On Wednesday, July 21, 2021 at 2:50 pm, LPA Rogers made contact with Born for Nia Facility Manager Winifred Hall to discuss the investigative finding of the allegation listed above. On July 21, 2021 at 3:19 pm, LPA Rogers conducted a safety inspection of the facility. No deficiencies were observed. During the course of the investigation, LPA Rogers interviewed Executive Assistant, Staff (S1-S2), Clients (C1-C3), Adult Female (A1), Adult Male (A2) and County Social Workers (CSW1 & CSW2). The following documents were obtained from the facility: Placement Agreements (C1-C3), Facility Sketch, Client Roster, Staff Roster, Copy of Protocol for Community Passes & copies of community passes. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Christina Barnes LICENSING EVALUATOR NAME: Latricia Rogers 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 19-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, MAIN ST., SUITE FACILITY NAME: BORN FOR NIA MATERNITY HOMEFACILITY NUMBER: VISIT DATE: 07/21/2021

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

met_with: Winifred Wall- Facility Manager


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Additionally, when the facility does the grocery shopping no breakfast foods are purchased and, that the food in the refrigerator is usually spoiled or freezer burned. Confidential interviews revealed, that clients were using their own food stamps to purchase food for the clients in the facility to eat. Receipts provided to LPA showed that many of the food items on the receipts for one month were frozen burritos, hot dogs and snack foods. LPA was also informed that it was the client's responsibility to take food out to defrost for dinner. If the food was not taken out in the morning before leaving for school, dinner meals were not prepared for the clients to eat. LPA was further informed that the facility does one big shop during the month with subsequent shopping every week thereafter. The receipts provided to LPA from the facility did not reflect additional shopping days during the month. Based on interviews, the preponderance of evidence standard has been met in regard to the allegation that staff does not ensure clients are properly fed while in care. Therefore, the allegation is Substantiated. This poses a potential Health, Safety or Personal risk to clients in care. Facility is cited for violation of Interim Licensing Standards v.4.1, regulation 87078(d)(2)-RESPONSIBILITY FOR PROVIDING CARE AND SUPERVISION An exit interview was conducted and a copy of this report and appeal rights were provided to Windy Hall, Facility Manager.

Investigation Findings:
13On Friday, October 22, 2021 @ 12:25 pm, Licensing Program Analyst (LPA) Latricia Rogers met with the Born for Nia Maternity Home Facility Manager, Windy Hall, to deliver findings of the above allegation. On June 22, 2021 at 2:54 pm, LPA Rogers conducted a safety inspection of the facility. No deficiencies were observed. During the course of the investigation, LPA Rogers interviewed Facility Manager, Facility Staff and 4 clients. The following documents were obtained: Placement Agreement, Client Roster, Staff Roster, Menu & Receipts. On June 18, 2021, Community Care Licensing received information that Staff did not ensure minors were properly fed. During confidential interviews it was stated that staff would buy food but nothing was bought to make whole meals. Confidential interviews also disclosed that a client had been at the facility for one month, no staff had gone grocery shopping and there was no food for meals in the refrigerator. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Christina Barnes LICENSING EVALUATOR NAME: Latricia Rogers 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 19-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, MAIN ST., SUITE FACILITY NAME: BORN FOR NIA MATERNITY HOMEFACILITY NUMBER: VISIT DATE: 10/22/2021

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

met_with: Windy Hall- Facility Manager

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
Per confidential interviews reported that if not all remaining clients accompany the staff to transport the client to their medical appointment, it would be rescheduled to avoid lack of supervision. Additional confidential interviews revealed that the documentation is filed in the client's file when the client goes to the appointment. In addition, the appointment would be written on the hard copy calendar in the staff office. However, the calendars are not saved for documentation. LPA observed that the last documentation of an appointment was from December 2021. The facility provided additional information to the Department, indicating that C1 attended a few medical appointments. Based on inconsistent record-keeping and confidential interviews, the allegation that staff are not meeting foster child's medical needs, may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Facility Manager, Sionna Shannon. This report serves as an amendment to LIC9099 report created on 12/06/2022. Type B citation rescinded.

Investigation Findings:
13On December 6, 2022, at 12: PM, Licensing Program Analyst (LPA) Leslie Covarrubias met with Facility Manager (FM) Sionna Shannon to deliver the findings for the above-stated allegation. On 01/27/2022 at 1: PM, LPA Latricia Rogers inspected the physical plant and observed no immediate health and safety hazards. The investigation included an interview with Clients (C1, C3, C4, C5, and C6), Staff (S1-S2) and County Social Worker. LPA attempted to interview and make contact with Client 2 (C2) but was unsuccessful due to C2 whereabouts being unknown. The Department received an allegation on January 20, 2022, that staff (S1) are not meeting foster child's (C1's) medical needs. Confidential interviews revealed that C1 and C2's appointments would often get rescheduled intentionally by S1. Additional confidential interviews revealed that C1, C2, and S2 did not get along; therefore, only C1 and C2's appointments would get rescheduled by S1. Other confidential interviews revealed that C1 and C2 would not make their appointment due to insufficient staffing. (Continue on next page...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Leslie Y Covarrubias 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 19-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, MAIN ST., SUITE FACILITY NAME: BORN FOR NIA MATERNITY HOMEFACILITY NUMBER: 366426844

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

met_with: Facility Manager (FM) Sionna Shannon


raw_content:
Narrative:
Based on inconsistent confidential interviews, the allegation that staff (S2) is giving minor (C1) money to buy a vape may have occurred; however, this is not supported by evidence. Therefore, the allegation is unsubstantiated at this time. A copy of the report LIC 9099 and the Appeal Rights were discussed and provided to FM Sionna Shannon.

Investigation Findings:
13On December 6, 2022, at 12: PM, Licensing Program Analyst (LPA) Leslie Covarrubias met with Born For Nia Maternity Home (STRTP), Facility Manager (FM) Sionna Shannon to deliver the findings for the above-stated allegation. On 6/24/2022 at 2: PM, LPA Covarrubias inspected the physical plant and observed no immediate health and safety hazards. The investigation included interviews with Clients (C1-C5), Staff (S1-S2), and County Social Worker. The Department received an allegation on June 23, 2022, that staff (S2) gave a minor (C1) money to buy a vape. Other confidential interviews revealed that S2 took the clients to a smoke shop and would, on a few occasions, allow the clients to smoke in the facility. Confidential interviews revealed that S2 did not provide any clients with substances, nor did S2 give any client money to purchase vape pens. Confidential interviews reported that S2 is not leaving the facility with clients during the time S2 works at the facility. (Continue on next page...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Leslie Y Covarrubias 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 19-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, MAIN ST., SUITE FACILITY NAME: BORN FOR NIA MATERNITY HOMEFACILITY NUMBER: VISIT DATE: 12/06/2022

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

met_with: Facility Manager, Sionna Shannon


raw_content:
Narrative:
Based on inconsistent confidential interviews, the allegation that due to lack of supervision, staff (S2) is allowing minors (C1-C4) to smoke marijuana in the group home may have occurred; however, this is not supported by evidence. Therefore, the allegation is unsubstantiated at this time. A copy of the report LIC 9099 and the Appeal Rights were discussed and provided to FM Sionna Shannon.

Investigation Findings:
13On December 6, 2022, at 12: PM, Licensing Program Analyst (LPA) Leslie Covarrubias met with Born For Nia Maternity Home (STRTP), Facility Manager (FM) Sionna Shannon to deliver the findings for the above-stated allegation. On 10/27/2022 at 9: PM, LPA Covarrubias inspected the physical plant and observed no immediate health and safety hazards. The investigation included interviews with Clients (C1-C4), Staff (S1-S2), and County Social Worker. The Department received an allegation on October 25, 2022, that due to lack of supervision, staff (S2) is allowing minors (C1-C4) to smoke marijuana in the group home. Confidential interviews revealed that S2 would smoke with the clients (C1-C4) in the facility's living room. Confidential interviews revealed that S2 would not allow any clients (C1-C4) to smoke, and if S2 did find anyone smoking, S2 would confiscate the contraband and report it. (Continue to next page...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Leslie Y Covarrubias 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 19-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, MAIN ST., SUITE FACILITY NAME: BORN FOR NIA MATERNITY HOMEFACILITY NUMBER: VISIT DATE: 12/06/2022

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


raw_content:
Narrative:
Confidential interviews reported that regarding the chores the minors will need to complete their chores before any outings. Confidential interviews reported that if a minor does not want to complete another minor can complete the chore for extra allowance. Confidential interviews reported that staff did not force any minors to visit the other facility or complete chores, however staff may stop by at the other facility to pick something up or on their way back to the facility. The interviews that were provided to the LPA were not consistent regarding the allegations listed above and interviews did not provide any further specific details. Based on interviews and record reviews staff did not keep C1's information confidential, staff #1 (S1) speaks to the minors inappropriately, staff (unknown name) was working at the facility being under the influence, staff forced C1 to perform chores and staff forces the minors to visit another facility, may have occurred, however is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Sionna Shannanon.

Investigation Findings:
13On December 15, 2022 at 10:20am, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced inspection to the facility to deliver the findings of the above allegations. LPA met with facility manager Sionna Shannanon. LPA Latricia Rogers conducted an inspection of the facility on December 21, 2021 at 11:41 am and no immediate deficiencies were observed. Four of four children (C1, C2, C3, C4), three staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that staff did not keep C1's information confidential, staff #1 (S1) speaks to the minors inappropriately, staff (unknown) was working at the facility under the influence, staff forced C1 to perform chores and staff forced the minors to visit another facility. Confidential staff interviews reported that C1 overheard S1 tell the minors that C1 had surgery. Confidential staff interviews reported that the minors could tell that C1 had surgery but did not know details about the surgery. Confidential staff interviews reported that staff did not make inappropriate comments to any of the minors. Confidential interviews reported that it is unknown which staff arrived to the facility under the influence of alcohol. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz 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 19-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, MAIN ST., SUITE FACILITY NAME: BORN FOR NIA MATERNITY HOMEFACILITY NUMBER: VISIT DATE: 12/15/2022

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

met_with: Sionna Shannanon


raw_content:
Investigation Findings:
13On December 15, 2022 at 10:56 am, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced inspection to the facility to deliver the findings of the above allegations. LPA met with facility manager Sionna Shannanon. LPA Latricia Rogers conducted an inspection of the facility on January 06, 2021 at 10:28 am and no immediate deficiencies were observed. Four of four children (C1, C2, C3, C4), three staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that staff does not treat C1 with dignity and respect. Confidential interviews reported that staff turns off the wifi and therefore C1 is unable to make any phone calls. Confidential staff interviews reported that staff does turn off the wifi as a form of discipline, however the facility phone landline is always accessible to the residents including C1 to make phone calls. The interviews that were provided to the LPA were not consistent regarding personal rights violation and interviews did not provide any further specific details. Based on interviews and record reviews the allegation that staff does not treat C1 with dignity and respect, may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. Exit interview was conducted, appeal rights explained, and a copy of this report was provided to Sionna Shannanon. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

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


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
with a preponderance of evidence. According to confidential interviews, Staff # 1 (S1) left C1's baby (IN1) inside a car seat with a soiled diaper for more than two hours on at least one occasion. According to confidential interviews, S1 was indifferent when confronted about it by one of the other clients. Confidential interviews also corroborated allegation that S1 would encourage clients to fight, and that S1 tried to coerce C1 and C2 into fighting Child #4 (C4). Based on interviews and information gathered during the investigation, the preponderance of evidence standard has been met and the Department has determined the allegations that Staff # 1 (S1) encouraged minors to fight and did not meet Infant's (IN1) needs while in care, as a result of IN1 being left in a car seat with soiled diaper for extended period of time is substantiated. The facility is issued a citation for the staff's actions, which posed an immediate and potential health and safety or personal rights risk to the children placed in care. These actions are in violation of the Interim Licensing Standards, Chapter 7. Version 4, Sections 87078(a) Responsibility for Providing Care and Supervision and 87072(c)(11) Personal Rights. See attached LIC 9099D for cited deficiencies. An exit interview was conducted, and a copy of the report and appeal rights were provided. corroborate the allegations with a preponderance of evidence. LPAs obtained conflicting information during interviews. Confidential interviews denied that staff # 1 (S1) was paying minors to change diapers, as well as did not ensure that Child # 2 (C2) attended school. According to confidential interviews, S1 always encouraged C2 and other children to attend school. Confidential interviews also denied that S1 and other facility staff was not logging in diaper changes, and stated that whenever a client has their diaper changed or has a bowel movement it is always logged in. LPA Mena was shown examples of diaper changing logs. While other confidential information received by Licensing Office stated that these allegations had occurred. There were no other known witnesses to these allegations. Based on interviews and confidential information obtained during the course of this investigation, the allegations that Staff # 1 (S1) did not ensure that a minor attended school, is paying minors to change diapers while in care and that facility has inadequate record keeping, more specifically that S1 was not logging in infant's diaper changes, may have occurred, however is not supported or proven by evidence. Therefore, the above allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided

Investigation Findings:
13Licensing Program Analyst (LPA), Daniel Mena met with Facility Manager, Sionna Shannon to issue the finding for the above stated allegations. An investigation was conducted by LPAs Latricia Rogers and Daniel Mena regarding allegations. LPAs Rogers and Mena conducted investigations to the Short Term Residential Therapeutic Program (STRTP) on February 10, 2022 and on January 04, 2023. LPAs Rogers and Mena interviewed three of four clients (C1, C2 & C3), four staff (S1, S2, S3 & S4), County Social Worker (CSW), as well as reviewed client and facility information. LPA Mena was unable to interview Child # 4 (C4) due to their current whereabouts being unknown. Community Care Licensing received information on January 31, 2022 alleging that Staff # 1 encouraged minor's to fight and did not meet Infant's needs while in care, as a result of infant (IN1) being left in a car seat with soiled diaper for an extended period of time. Confidential interviews conducted by LPAs Rogers and Mena corroborated allegations SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Daniel Mena 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 19-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, MAIN ST., SUITE FACILITY NAME: BORN FOR NIA MATERNITY HOMEFACILITY NUMBER: VISIT DATE: 01/13/2023

met_with: Sionna Shannon


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On May 7, 2026, at 3: PM Licensing Program Analyst (LPA) Carissa Aviles met with Born for Nia Short-Term Residential Therapeutic Program (STRTP) Lead Facility Manager (LFM) Sionna Shannon for a Case Management visit inspection. The purpose of the inspection was to address an issue and concern observed during the review of an incident that occurred on or around March 26, 2026. During confidential interviews and file reviews, Client 1 (C1), see confidential names list (LIC 811) dated May 7, 2026, had an incident that involved the Department of Social Services and Law Enforcement. On April 21, 2026, LPA spoke to LFM and was informed that a Special Incident Report was sent to the Department notifying the incident occurred within reporting requirements. LPA searched C1 file and did not see a Special Incident Report. After further review a Special Incident Report for the incident that occurred on or around March 26, 2026 was not sent to the Department per reporting requirements. LFM confirmed that the Special Incident Report was not sent to the Department. Based upon confidential interviews and record review the facility is being cited for 87061(j), Reporting Requirements - the licensee shall submit reports to the Department, using form LIC 624-LE or a report containing all the information required in LIC 624-LE, regarding any incident that involves law enforcement contact with a child in the facility. The licensee shall make an initial report to the Department no later than the next business day following each incident. The facility will be issued an immediate civil penalty of $250. An exit interview was conducted, a copy of this report, LIC 811, LIC 809D, LIC 421FC, and appeal rights were reviewed and provided to the facility representative.

Deficiencies:
87061(j): the licensee shall submit reports to the Department, using form LIC 624-LE or a report containing all the information required in LIC 624-LE, regarding any incident that involves law enforcement contact with a child in the facility. 1
2
3
4
5
6
7POC to send a 24 hour notification to the Department notifying an incident has occured per the Reporting Requirements.

Licensee to complete a training on Reporting Requirements. Licensee to send the training roster via email to LPA by POC due date.
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9
10
11
12
13
14

report_type: Facility Evaluation

visit_type: Case Management

met_with: Lead Facility Manager Sionna Shannon

title:
1
2
3
4
5
6
7REPORTING REQUIREMENTS (j)


facility_name: BOULEVARD GROUP HOME

summary: Facility Evaluation

raw_content:
Narrative:
On 7/9/ Licensing Program Analyst (LPA) Reagan Cohen conducted the Component II - Face to Face Interview with Applicant Sheila Hatcher. Application and program statement was reviewed and discussed with Applicant. The applicant will oversee Boulevard Group Home (STRTP). The following documents were received and verified by LPA: 1. LPA verified and signed the orientation certificate for Component II. 2. LPA made a copy of Applicants ID for the records. 3. LPA observed that the criminal record clearance has not been approved yet for Applicant. LPA informed Applicant that LIC 200 needs to be resubmitted with a new name that does not include Group Home because it is an STRTP facility, and also the age group of the facility. Applicant will also resubmit LIC 401, LIC 500, LIC 999. Applicant will also add verbiage that the facility will not with hold client cash/allowances as punishment. Applicant will add a Table of Contents. Applicant will revise and resubmit application and Program Design by 7/16/25. LPA scheduled a Pre-Licensing visit for Boulevard for 7/24/25 at PM. A copy of this report was given to the applicants. Exit interview completed.

met_with: Sheila Hatcher


summary: Facility Evaluation

raw_content:
Narrative:
On 7/24/25, Licensing Program Analyst (LPA) Reagan Cohen arrived at the above facility, for the purpose of conducting a Pre- licensing inspection for an STRTP. LPA met with applicant Sheila Hatcher, who granted access into the home. The applicant and LPA toured the facility both inside and out. Applicant is requesting to be licensed for 4 clients ages 16-21 ambulatory only. The home was inspected and the following was observed This is a one-story house, with a front yard, backyard, and drive way. There are working duel smoke/carbon monoxide detector in every bedroom. They are synched throughout the house. Living Room: There is adequate lighting and air conditioning. There is a TV. There are 2 sofas that provide adequate seating. There is a coffee table. There is a landline in the living room. The living room leads to the kitchen/dinning area. Dinning Room/Kitchen: There is a dinning table with 4 chairs. There is a mini fridge that will hold snacks. There is a water cooler for clients to use. There are shelves along the wall for snack storage. There is a fridge/freezer with adequate storage space for food. There is a stove with 5 burners and an oven. There is a microwave and air fryer. There is adequate storage space for food, cooking supplies, and utensils. LPA observed an adequate amount of non perishable food, utensils, plates, cups, bowls, cooking tools, pots, & pans. The first aid kit is stored in the kitchen, it is complete with scissors, tweezers,gauzes, bandages, and antiseptic solution. There is also a first aid manual. This room leads to the office, bedroom #1, and to the hallway. There are no knives or cleaning solutions stored in the kitchen. Office: There is an office room for staff only. It must be made inaccessible to clients. There is a computer and printer. There is a closet that is storing all cleaning solutions and hygiene products. There is a cabinet for storage for staff and client files. There is a freezer for medication storage. There is a TV. There is a door that leads to the backyard. The office will not be used as a passageway to the back yard. Bedroom #1: For clients. The room has 2 beds, lights, AC, a closet, 2 dressers, extra linens and towels. There is one window with adequate screen covers and which opens for emergencies. After this room starts the hallway to the bathroom and bedroom #2. Bathroom #1: The bathroom is equipped with a toilet, shower, and sink. The sink temp was measured to be 120 degrees F. There are working lights and a fan. There are no cleaning solutions in the bathroom. Hallway: The hall way has a fully charged fire extinguisher. There is a wall heater in the hallway that is non operational/decommissioned. Bedroom #2: The bedroom is for clients. The room has 2 beds, lights, AC, a closet, 2 dressers, extra linens and towels. There are 2 windows with adequate screen covers and 1 which opens for emergencies. Front Yard: There is a front porch with 4 chairs. There is a front yard with adequate space for clients to hang out. There is a camera in the front yard. Driveway: There is a driveway along the side of the house that leads to the backyard. There is a gate that will be made accessible to the backyard. Backyard: There is a washer dryer set accessible to clients in the backyard. There are desks in the back yard for clients to use. There is adequate space for clients to run around and hangout. There are two cameras in the backyard. The backyard is free of debris. LPA will return to ensure that: Personal rights are posted in a public area Sample activity schedule and menu are posted in a public area Emergency/disaster plan is posted in a public place The office can lock and be made inaccessible to clients A trash can with a fitted lid is added A thermometer is added to the first aid kit A personal lock box is available for clients that will store their personal items that they have access to Complaint procedures are set up including a instructions, grievance forms, and a lock box to submit forms Laundry baskets and hygiene basket is available to clients An adequate amount of books, board games, and card games are available to clients Facility vehicle is in working order with insurance LPA will email applicant a copy of the facility cameras PIN Applicant and LPA agreed that LPA will return on 8/7/25 to ensure changes were made. Exit interview was conducted and a copy of this report was given to the applicants.

visit_type: Prelicensing

met_with: Sheila Hatcher Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 8/7/25, Licensing Program Analyst (LPA) Reagan Cohen arrived at the above facility, for the purpose of conducting a Pre- licensing inspection continuation for an STRTP. LPA met with applicant Sheila Hatcher, and continued the inspection by completing the CARE Tools and ensuring that all the previous observed missing items were added and fixed. LPA toured the facility that facility with the applicant. LPA observed the personal rights posted in a public space. LPA observed the the sample menu and activity schedule posted. A observed the emergency plan posted in a public place. observed the office being able to lock and can be made inaccessible to clients. LPA observed a trash can in the kitchen, and a thermometer with the first aid kit. LPA observed personal lock boxes for each client. LPA observed a grievance procedures lock box for clients to submit into. LPA observed a laundry and hygiene basket filled with toiletries for each client. LPA observed the facility to be filled with books and games/activities for clients. LPA observed the insurance and registration for the facility vehicle and LPS observed the vehicle to be in working order. LPA talked with applicant about the next steps and reviewed the CARE tools requirements for running the facility with the applicant. No deficiencies observed. LPA scheduled a component 3 meeting with the applicant for 8/14/25. Exit interview was conducted and a copy of this report was given to the applicant.

met_with: Sheila Hatcher Applicant


summary: Facility Evaluation

raw_content:
Narrative:
On 10/21/25 at PM LPA Reagan Cohen and LPM Lakescia Smith met with Applicant Sheila Hatcher and Ebony Streets at the El Segundo Regional Office for the purpose of a technical Assistance Meeting. System of Care representatives Cynthia Galindo and Marjana Jackson were present via zoom. The purpose of the meeting was for CCL and SOC to discuss the revision regarding the Facilities proposed Plan of Operation and Program Statement (POO/PS). The following items were discussed: Redoing the binder numbering to match the POO/PS Section D - Staff Plan G. Admission Determination Procedures H. Intake Policies and Procedures Section I Admission Agreement: Section J Removal and/or Transfer Policies and Procedure M. Consultants and Community Resources Utilized Plan of Opration 1. Population to be Served 4. Core Services and Supports 5. Trauma Informed Interventions and Treatment Practices 7. Development, Implementation, and Modification of Needs and Services Plan 8. Planned Activities 9. Services During Placement and After Discharge 7. Describe how the program will support caregiver staff in identifying and accessing services and supports to heal from trauma, including, for example, how they will address secondary trauma experienced by staff · Need to show specific training hours; training hours don't match · Need training assessment · Stated that there will be outside training, be specific, who will lead training & what topics will be covered? · Info on engaging and working with child's family and community · More cultural sensitivity G. Admission Determination Procedures 1. Determination procedures do not include a detailed explanation of how the program will evaluate the appropriateness of placement for referred children with any of the following behaviors or characteristics, including how the licensee defines these characteristics for the purposes of assessing appropriateness of fit: · Frequent runaways · Gang-related activity · Firestarting · Sexually assaultive behaviors · History of Commercial Sexual Exploitation · Substance abuse 2. Need to include a statement that the list of behaviors or characteristics (above list) shall not be utilized as the sole basis to determine the appropriateness of placement and/or deny admission. If the STRTP intends to deny admission, there needs to be an explanation of why the referral was denied. For example, STRTP cannot simply state, "if a referral indicates they will burn the property if admitted, they will not be admitted". STRTP MUST engage in a good-faith effort to determine the appropriateness of the placement. 3. This section mentions a 24-hour window to share the admission decision. However, need to include specific timeframes to respond to referrals for placement, as set forth in ILS Section 87068.05(c)(4): · The established timeframes must include, but are not limited to, an initial response period in which the facility accepts, denies, or requires more information for the consideration of the referral for placement and; · A final response period in which the facility accepts or denies the referral for placement. 11. Identification of Home-Based Settings and Family-Based Aftercare Support Plan and Aftercare Service12. Family and Sibling Participation 16. Personal Rights 17. House Rules for Child(ren)/NMDs 24. Mental Health Program Approval 26. Emergency Intervention Plan (Runaway Plan) LPA gave applicant a copy of the detailed notes regarding the revisions for each section. Applicant agreed to turn in the revisions by 11/4/ Applicant informed LPA that Ebony Streets would be the administrator for the facility. LPA informed applicant that Ebony would need to turn in their proof of qualifications, LIC 501, proof of completing component orientation 1,2,&3, and get transfer clearance to the facility. LPA and Applicant discussed the outstanding fire clearance. LPA will reach out to the local fire authorities to request a fire clearance. Exit Interview Conducted. A copy of this report was given to the applicant. N. Trauma-Informed Intervention and De-Escalation Techniques Q. Continuous Quality Improvement (CQI) Program Statement 1. Population to be Served 1. Specify if the facility intends to serve children or NMDs with special health care needs. 2. Does not include a description of how the facility programs have the ability to support: I. The individual needs of children, NMDs, and their families, with short-term, specialized, trauma-informed, and intensive treatment, including, but not limited to, treatment that implements child-specific short-and long-term needs and goals identified by the qualified individual's assessment of the child II. Children, NMDs, and their families from different backgrounds or experiences, including race, ethnicity, sexual orientation, gender identity, or a child/NMD who is gender non-conforming. 4. Core Services and Supports 1. Attach agreement(s), if any, with other agencies that provide core services and supports, and provide information on how the STRTP will ensure that the core services secured through agreements with other agencies are trauma informed and culturally relevant. 5. Trauma Informed Interventions and Treatment Practices 1. Demonstrate how the program addresses each of the following: · A child or NMD's needs to feel safe, respected, informed, connected, and hopeful regarding their own experience with trauma. · The interrelationship between trauma and the impacts of trauma includes, but is not limited to, neuro-cognitive problems, neuro-psychological issues such as depression and anxiety, and behaviors. · The need to work in a collaborative way with a child or NMD, their family and friends, and human services agencies in a manner that will empower the child or NMD. · Interventions, techniques, and practices that are trauma-informed, culturally relevant, age and developmentally appropriate as provided by direct care staff to a child or NMD consistent with a child's or NMD's needs and services plan and treatment plan. 2. Describe how the STRTP will meet ILS requirements for a comprehensive trauma-informed treatment model designed to address the individualized needs of children as specified in Sections 87022.1 and 87078.2, and include a description of the trauma-informed interventions and/or treatment practices that will be used by the program to serve children, NMDs, and families, as specified in Sections 87022.1(b)(7) and 87078.2, including, but not limited to, the evidence-based or informed screening or assessment tools to identify trauma history and trauma-related symptoms or problems. 3. Explain how the interventions, practices, services support the following: · Recognition and understanding of the trauma that children have experienced and how trauma impacts children · How observable behaviors will be identified and evaluated to assess the need for services · Maximization of physical and psychological safety for the child or NMD · How emergency interventions, including early interventions and de-escalation procedures, are trauma-informed 4. What screening or assessment tools will be used to identify trauma history and trauma-related symptoms or problems, and how that history is included in the child's Needs and Services case plan or Treatment plan within 30 days of admission. 5. Provide the procedures for how the provider will access and make referrals for evidence-based and/or promising services and practices that are trauma-informed · Missing whole sections 6. Licensed Nursing Staff 7. Development, Implementation, and Modification of Needs and Services Plan 1. Missing crisis management plan as an identified need. 2. There is duplicate information in this section. Recommend revising for clarity. 3. This section does not refer to a qualified individual. Please explain how the services will meet the short and long-term needs and goals of the youth. 4. Specify how the discussion with the youth will be age and developmentally appropriate and documented in the youth's NSP. 5. Missing requirement listed in section 87068.2(d)-(g). 6. Specify procedures for when the STRTP does not receive the case plan from the county placing agency. 7. Please note that section 87068.2 does not apply to NMD, therefore, please refer to section 87068.22 and specify how the STRTP will meet the requirements of that section. 8. The procedures for modifying the NSPs are not clear. It mentions that STRTP will analyze incident reports that occurred within the 30-days, but it's not clear what the purpose of this analysis is, nor its frequency. 9. Missing requirement listed in section 87068.3(b)(1)-(2). 10. Incident report analysis is missing requirements listed in section 87068.3(c)(1)(A)(1)-(6). · Add Reasonable & Prudent Parenting Standards (RPPS) 8. Planned Activities 1. Planned activities do not address access to computer technology and the internet, consistent with the youth's age, maturity, developmental level, court order, and CFT decision. 2. Does not include the development of community support systems for youth to maximize utilization of non-mental health community services and other resources. 3. The STRTP intends to serve young parents, but there are no planned activities that apply to that population. 4. The planned activities meet the needs of minor and NMD parents and their children. · Add vocational counseling activities · Add Community support activities 9. Services During Placement and After Discharge 1. Please note that the STRTP cannot provide mental health services until approved to do so. Please explain how the STRTP will ensure that youth receive mental health services. 2. Please specify how the STRTP will provide the services mentioned on the first page of this section. 3. Missing the name, location, and services provided by an agency or agencies that the applicant or licensee has partnered with, either formally or informally, to provide additional support and services to families and children including NMDs during care and post-permanency 10. Plan for Participation in Child and Family Team ("CFT") 11. Identification of Home-Based Settings and Family-Based Aftercare Support Plan and Aftercare Services 1. Explain how the facility, in accordance with the child's case plan and the CFT recommendations, will provide for, arrange for the provision of, or assist in, all of the following: ·Development of an individualized family-based aftercare support plan that identifies necessary supports, services, and treatment to be provided for at least six months postdischarge as a child moves from the STRTP to homebased family care setting or to a permanent living situation through reunification, adoption, or guardianship, or to a transitional housing program. This plan shall be developed, pursuant to WIC section 4096.6, in collaboration with the county placing agency, the CFT, and other necessary agencies or individuals for at least six months postdischarge. · Aftercare services may be provided by the following including, but not limited to: a STRTP, county placing agency, child welfare agency, probation department, mental health plan, or other agencies or individuals pursuant to WIC section 4096.6. Documentation of the process by which the STRTP will implement treatment and services to support the short- and long-term, child-specific mental health goals identified by a qualified individual pursuant to WIC section 4096(g). 12. Family and Sibling Participation 1. There is no mention of consulting with the youth regarding the preferred family members they would like to interact with per section 87022.1(b)(13)(A). 2. Document how family members will be integrated into the treatment process for the child, including postdischarge, and how sibling connections are maintained. · Need to work with child's family, friends, and community. 14. Participation and Assistance in Initiatives to Improve the Child Welfare System 16. Personal Rights 1. Describe the measures in place to ensure that youth are informed of how to contact appropriate agencies regarding potential violations of their rights before such violations occur. 2. Explain how personal rights competency & identifying personal rights violations competency are evaluated for each youth? 3. How will the STRTP ensure that youth rights are explained in an age and developmentally appropriate way per 87072(b)(2)? 4. Missing. Ensure that copies of all laws related to the filing of complaints at admission, at the child's request, and each time a new right has been added to the Section or Welfare and Institutions Code section 16001.9., per 87072(b)(2) 5. Provide PROCEDURES that demonstrate compliance with personal rights. 6. Include or reference the personal rights form. · Sample Personal rights · List rights · Staff training on personal rights 17. House Rules for Child(ren)/NMDs 1. What happens to the chores if the youth refuses to complete them? 2. This section mentions a level system. Explain how the level system is trauma-informed and meets the requirement of providing individualized care. 3. Specify the curfew for minors and NMDs. 4. This section states that no new piercings are allowed. Does that same rule apply to NMDs? 18. Positive Discipline Policies and Procedures- This section is missing. 1. Cover Sheet with number/letter and name of section 2. Provide a description of positive discipline policies and procedures describing type(s) of discipline permitted and rationale, conditions under which each type of discipline will be used, types of discipline not permitted, and provisions for informing the child's or NMD's authorized representative(s) of discipline policies, as specified in Section 87072.1. The description must include how the types of discipline are trauma informed. 3. Provide a description of how trauma-informed practices are embedded in the provider's discipline procedures, as well as how discipline policies account for the particular nature of youths' trauma (including specialized populations) 4. Expectations and consequences, including policies and procedures for NMDs. Specify: · Discipline policies and procedures not applicable to NMDs · Consequences for NMD when they do not comply with reasonable expectations 19. Expectations and Consequences for NMDs- This section is missing. 22. Child(ren)'s Direct Input 23. Documentation of Accreditation 24. Mental Health Program Approval 1. It is not clear how the facility will ensure access to mental health services, including specialty mental health services and mental health supports that meet short and long term mental and behavioral health goals and treatment as identified by the qualified individual, as appropriate to the needs of the child or NMD in its care, as set forth in Section 87089.1(d), that shall include all of the following: I.Ensuring continuity of care, services, and treatment as a child moves to home-based family care or to a permanent living situation, in accordance with the child's case plan or treatment plan II. Documenting the child's ability to access mental health services identified in the needs and services plan, or efforts made by the STRTP to ensure access to identified mental health services, including utilization of any existing grievance processes for accessing services. 2. Specify the community providers and external providers who will assist with providing services to youth. 3. An STRTP providing care and supervision to children diagnosed by a physician, psychologist, or licensed clinical social worker as mentally disordered shall make provision for at least monthly consultation from a psychiatrist, or clinical psychologist, or licensed clinical social worker regarding the program of services, or more often as appropriate to the needs of the child or NMD. · Intensive Day Treatment Services = Intensive Home-Based Services? · Missing Day Rehabilitation Services · Missing Therapeutic Behavioral Services 26. Emergency Intervention Plan (Runaway Plan) 1. Missing procedures for notifying staff that a youth is absent at the change of shift. 2. This section mentions that manual restraints will be used if a youth is a danger to themselves. This is a violation of section 87095.01. Recommend rephrasing or changing this sentence. 3. Specify time frames for reporting unauthorized absence. 4. What will happen if there isn't enough coverage by other staff to supervise residents if a youth is trying to leave the home? 5. Specify the Emergency Intervention techniques that will be used to prevent runaways. 6. Missing requirement listed in section 87095.24(c)(9). 7. Missing requirements listed in section 87095.68.

met_with: Applicant Sheila Hatcher


facility_name: BOURNE INC. - HILL

raw_content:
Investigation Findings:
13On July 16, 2024, Licensing Program Analyst (LPA) C. White arrived Bourne Inc. - Hill for the purpose of delivering findings for a complaint investigation. LPA met with Facility Manager, Nick Walker. During the course of this investigation, LPA conducted confidential interviews and reviewed records. Confidential interviews and documentary evidence did not produce corroborating proof to support the allegations. Based on information obtained during the investigation, the allegations are found to be unsubstantiated, meaning although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a has violation did or did not occur. There are no deficiencies cited at this time. An exit interview was completed, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Bernice Karnsrithong LICENSING EVALUATOR NAME: Charmetha White LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Nick Walker - Facility Manager


raw_content:
Investigation Findings:
13Licensing Program Analyst Connie Jones-Steward investigated the above allegations. LPA interviewed staff, , DCFS social workers, and the mother of C1. LPA was not able to contact C1, LPA also reviewed related incident reports and the Needs and Services Plan for C1. Per the NSP and staff interviews, only the father of C1, his sister or his social worker were to be notified of incidents. However his social worker nad his mother refute this information and state that the facility was notified to contact the mother as well. Based on conflicting information and evidence, thie allegation that staff did not notify minor's authoriized representatives of incidents is resolved as unsubstantiated. Unsubtantiated means that even though an allegation may have happened or is true, there is not enough evidence to prove that it did happen. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Lauren Bennett, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On October 18, 2021 at 10am Licensing Program Analyst (LPA) Donald Martin arrived at the main office of Bourne Inc. for the purpose of conducting an Annual Inspection. LPA was met by Administrator, Barbara Waffer and allowed into the Office located at N. Lake Ave Altadena, CA. 91001. LPA began with the review of the Staff files. LPA reviewed 3 staff files. All files contained all documentation necessary to be employed at the facility. All employee files were in outstanding order. LPA will continue the facility inspection, client files and interviews at N. Hill Ave. Pasadena, Ca. 91104. There were no deficiencies to cite at the time of this visit.

visit_type: Annual

met_with: Barbara Waffer-Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 10/20/2021 at 12:30pm, Licensing Program Analysts (LPA), Donald Martin arrived at the above facility for the purpose of conducting an Annual Inspection Continuation. LPA was met by Dino Wilburn, Facility Manager who conducted the tour of the facility. The facility is licensed to care for six clients, ages 12 -17 years, ambulatory only. The facility also provides services to Non-Minor Dependents pursuant to W&I CODE 16501.1(C)(1). The facility was set as follow: This is a single story home located in a residential area. The home has 3 bedrooms, 2 bathrooms, living room, dining area, kitchen, therapy room, laundry room and detached garage. No bodies of water on the premises. Living Room: Has a fireplace with required security screen. Kitchen: Kitchen was equipped with refrigerator, 4 burner gas stove (operable at the time of inspection), oven, and microwave. Bedroom #1 is equipped with two twin size beds, dresser space, has adequate lighting and closet space. Bedroom #2 is equipped with two twin size beds, dresser space, has adequate lighting and closet space. Bedroom # 3 is equipped with two twin size beds, dresser space, has adequate lighting and closet space. Has bathroom inside of room and sliding door access to the porch on the rear of the home. Dining Area: has adequate space for required seating for clients. Bathroom: All 3 were clean and in good repair and toilets were operable, sinks and shower all had with running water Laundry Room: is located in the office/therapay room. It has a washer and dryer, has door which leads to the backyard. Outdoor Activity space: front and backyard was free from obstruction and debris. Detached Garage:in the backyard at the end of the driveway. (Continued on LIC 809-C) Detached Garage: the garage is used for extra storage space and contains a freezer for additional food, bikes, and household supplies. The garage remains locked at all time. All detergents and disinfectants are kept in the garage as well. LPA observed the following: Sharp knives and medications are kept in locked cabinets, inside a locked closet located in the staffing office. Extra linen is located in the Linen closet is located along the hallway. First aid kit was complete. The facility has one functioning carbon monoxide and several smoke detectors, all tested audible and were in proper working order. The facility has two (2) fully charged regulation fire extinguishers, one located in the hallway and the second located in the kitchen. There were no guns or weapons are in the home. There are no swimming pools or bodies of water on the premises. Central air and heating unit in the backyard. All window had screens, in good repair, and there are no security bars on the windows. The facility has one (1) vehicle to transport clients: a Honda Odessy 2010. The vehicle was inspected and found to be clean, in good repair, and has current automobile insurance is with Non-Profit Insurance. The following was discussed with the Facility Manager: Children will be accorded personal rights. Children in care will be supported, encouraged to participate in extracurricular activities. Children in care will be able to contact the licensing agency. Children in care will not be restricted in telephone use except by program choice. A working telephone line must be available for clients to use at all times. Hot water must be maintained between 105 and 120 degrees (F). Adequate supervision and protection must be provided for children in care. Staff will ensure three nutritious meals and snacks. Food supply must be ample in the home. The beds must have comfortable mattresses, clean linens, blankets, and pillows, to be maintained in good repair. The facility is currently operating within capacity and limitations of license. All posting requirements were met. Exit interview was conducted and a copy of this report was left with Facility Manager, Dino Wilburn.

met_with: Dino Wilburn-Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On October 4, 2022 at 10:31am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Bourne Inc (Hill) for the purpose of conducting a Case Management (Other). LPA met with Kashmeir Tucker, Administrator. The purpose of this visit is to discuss concerns regarding increased number of law enforcement service calls regarding AWOL of residents and missing persons reports for the facility. The census on the day of this visit is four (4). During this visit, LPA discussed the area of concern regarding the increased number of Missing Person's reports filed with Pasadena Police Department in 2022 as well as provisions of the Program Statement for Bourne Inc.(Hill) regarding their policy on AWOLS and how they will be addressed. LPA and Administrator discussed possible solutions to reduce the number of Missing Person reports filed with law enforcement such as ensuring Child and Family Team meetings are conducted to address AWOL concerns and ensuring Needs and Services plans reflect what issues such as chronic AWOL'ing are addressed. Administrator stated will follow-up with staff and Executive Director to address the concerns regarding clients AWOL'ing and the increased number of Missing Persons filed with local law enforcement. LPA requested a copy of the current LIC 500 for the facility. LPA reviewed the LIC 500 (Personnel Report) and CCL Personnel Summary which revealed discrepancies. LPA will review discrepancies and will research Criminal Record Clearances for Staff #1 - 10. LPA will follow-up with provider on a later date regarding Criminal Record Clearances for staff. LPA informed Administrator to ensure all staff are associated to the facility through the Guardian process. No deficiencies cited during today's visit. Exit interview was conducted, and a copy of this report will be emailed to the Administrator.

met_with: Kashmeir Tucker-Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On January 24, 2022 at 10:38am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Bourne Inc. (Hill) for the purpose of conducting a Case Management visit. LPA arrived at the facility to conduct an interview with Client #1 (C1) due to an incident which occurred at a previous placement. LPA met with Randi Lee, Direct Care Staff. LPA was informed that Administrator is at the agency's main office. LPA requested and was provided with a LIC 500. LPA provided facility with a new Foster Youth Bill of Rights poster. Based on the observations made during today's visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. Exit interview was conducted, and a copy of this report will be emailed to the Administrator.

met_with: Randi Lee-Direct Care Staff


summary: Facility Evaluation

raw_content:
Narrative:
On September 26, 2023 at 9:02 am, Licensing Program Analyst (LPA) Christine Wilson and Licensing Program Analyst (LPA) Jhane Haynes, made an unannounced visit to the above listed facility, in order to conduct a case management deficiency. LPAs were met by the Facility Manager (FM) who provided access to the facility. LPAs conducted a walk through of the facility. LPAs obtained copies of LIC 500, Client Roster, SIR dated 9/14/23, Shift notes, Intake packet for (C1). LPAs were unable to determine if there were any deficiencies at this time. A copy of this report was emailed to the licensee staff (FM), whose signature on this form confirm receipt of these documents.

met_with: Facility Manager (FM)


summary: Facility Evaluation

raw_content:
Narrative:
On November 20, 2023 at 1:00, Licensing Program Analyst (LPA) Deborah Lee and Licensing Program Manager (LPM) Lakescia Smith made an unannounced visit to Bourne Inc Hill for the purpose of conducting a Annual Random Inspection. LPA met with Nick Walker, House Manager who granted access to the facility. Thereafter Barbara Waffer, Administrator arrived to assist with inspection. The facility is licensed to care for six clients, ages 12 -17 years, ambulatory only. The facility also provides services to Non-Minor Dependents. Overview of facility: The Short Term Therapeutic Residential Program (STRTP) is a 3 bedroom, 2 bathroom home located in a residential area. living room has a sectional sofa, mounted TV, a non-operational covered fire place, 2 end tables, 2 chairs. There is a table designated for visitor sign-in. Dinning room has a 6 seated dinning table and a table with TV for gaming. There is a water dispenser located against the wall under a bulletin board that contains facility sketches and facility license. There is another bulletin board that contains client information. Kitchen has a stove in working order, two counter top air fryers, microwave oven, fully charged fire extinguisher, a dishwasher, covered waste basket. There is food supply meets title 22 regulations Washer and dryer is operable and located in room adjacent to staff office . Continued on 809C Bedrooms Bedroom1 is occupied by 2 clients, there are two twin bed that are in good repair with adequate linens, adequate drawer and closet space. LPA observed the two windows did not have window screens Bedroom 2 is occupied by 2 clients, there are two twin bed that are in good repair with adequate linens, adequate drawer and closet space. LPA observed that one window did not have window screens. Bedroom 3 is occupied by 2 clients, there are two twin bed that are in good repair with adequate linens, adequate drawer and closet space. LPA observed two windows did not have window screens. bathroom 1 was clean, sanitary and in good repair. Water temperature tested and within required range of 105-120 degree F Bathroom 2 was clean, sanitary and in good repair. Smoke detectors in each bedroom was tested and operable LPA observed linen closet to have adequate supply of clean linens. LPA reviewed LIC 500 and found 4 staff missing from Guardian association roster. LPA to follow up on individual clearance status of the 4 staff. LPA to return to facility to complete inspection: staff files, client files, staff and client interviews. Exit is completed and copy of report email to administrator

met_with: Barbara Waffer


facility_name: BOURNE INC. - LA CORONA

summary: Complaint Investigation - Unsubstantiated - 2 allegations

raw_content:
Investigation Findings:
13On 01/05/2024 at 12:55pm, Licensing Program Analyst (LPA), Christine Wilson met with Facility Manager (FM), and concluded the investigation of the above allegatiosn. During the course of this investigation, LPA Wilson conducted witness interviews, record reviews, and made observations. The investigation included confidential interviews with clients, facility and administrative staff. Based on all interviews conducted, and documents obtained, the Department has found the above allegations to be substantiated, meaning that, the preponderance of the evidence has been met. Supporting evidence includes witness accounts direct statements, facility reports, and medical reports of documentary validation. There are (1) deficiencies to be cited at this time (see LIC9099D). An exit interview conducted, plans of corrections reviewed with the licensee, and a copy of this report and appeal rights was left at the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Christine Wilson LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION WOODLAND HILLS S.Ro, Ventura Blvd., STE. Woodland Hills, CA Facility Name: Bourne INC. - LA CORONAFACILITY NUMBER: 198207575

Allegations:
- SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion: Based on all interviews conducted, and documents obtained, the licensee did not provide adequate care and supervision to minor in care, minor had access to an unknown drug substance, minor had access to cough medicine and minor was physically assaulted by other minors in care, which poses an immediate danger to the health safety and personal rights risk to persons in care.
- UnsubstantiatedEstimated Days of Completion: Unsubstantiated Estimated Days of Completion: Unsubstantiated Estimated Days of Completion:

met_with: Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 09/28/2021 9:30AM Licensing Program Analyst (LPA) Rosslyn Gray and LPA Bernice Karnsrithong made an unannounced to BOURNE INC. - LA CORONA for the purpose to conduct the Annual/Required licensing Inspection. LPA met with the Program Administrator, who granted access into the home, and who provided a tour of the entire physical plant inside and out. The facility is licensed to care for 6 clients, female only, ages 12 -17 years, ambulatory only. The facility also provides services to non-minor dependents. The facility acquired The National Accreditation through Commission on Accreditation of Rehabilitation Facilities (CARF) valid 05/11/2020 through 05/10/2022. There are no bodies on water on the premises. Staff confirmed that there are no firearms or dangerous weapons in the facility. There are no guns/weapons in the home. STRTP Overview: This is a one (1) story home, located in a residential area. This is a one (1) story, three (3) bedroom (STRP) Short Term Residential Therapeutic Program. There are three (3) bathrooms, living room, dining room, kitchen area. The garage is a detached from the main facility. 1 car garage has been converted into a laundry room used for storage. A portion of the garage is under construction for a therapy room. The administrator confirmed that the changes to facility will reported. Living Room: There is adequate furniture which appears to be in good condition. There is a television and fireplace that is non-operable. Dining Area: One table with six chairs. There is a book shelf that contains books and games for children to use. There is a staff sign-in area next to the dining area. Temperature and health checks are conducted in the sign-in area. Common Area: There is adequate furniture, television, and a coffee table. Kitchen: There is a gas stove/oven with four (4) burners, all operating. There is a microwave and refrigerator/freezer. There is a toaster oven and an air fryer in the kitchen. LPA's observed adequate perishable/nonperishable food supplies. Sharp knives, disinfectants/cleaning solutions, and medicines are made inaccessible to the children. (page 1 of 3) Water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. Bedroom # 1: Occupied by two (2) clients, has two (2) twin sized beds and comfortable mattresses, linen, blankets and pillows; adequate drawer and closet space. There is one (1) walk in closet. There is adequate lighting and the windows have vertical and horizontal slide locked with vertical shades observed to be in good condition. Bedroom # 2: Occupied by two (2) clients, has two (2) twin sized beds and comfortable mattresses, linen, blankets and pillows; adequate drawer and closet space. There is one (1) walk in closet. There is adequate lighting and the windows have vertical and horizontal slide locked with vertical shades observed to be in good condition. Bedroom # 3: Occupied by two (2) clients, has two (2) twin sized beds and comfortable mattresses, linen, blankets and pillows; adequate drawer and closet space. There is one (1) walk in closet. There is adequate lighting and the windows have vertical and horizontal slide locked with vertical shades observed to be in good condition. All Bathrooms: have toilets, sinks and tub/showers. All are in clean and operating properly. Water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. The Facility was inspected, and the following was observed: The home is clean, safe, sanitary, and in good repair. Carbon monoxide and smoke detectors are working properly. All fire extinguisher was fully charged. Smoke and carbon monoxide detectors were working properly in the facility. First Aid kit was complete with all required supplies. LPA observed a First Aid kit complete with scissors, tweezers, thermometer, gauzes, antiseptic and 1st Aid Manual. LPA observed carbon Monoxide alarms, located on each floor were observed and functional in the home. LPA observed five (3) fully charged fire extinguishers located throughout the facility. All posting requirements were met. Outdoor activity space is free of hazard materials and debris. LPAs observed that the perimeter screens of the house were in good condition. LPAs observed that there is a hot water heater that is enclosed and locked. LPAs confirm that staff were aware of the utility shut-off valves. Children will be accorded personal rights. The facility current License, Mental Health Certification; Ombudsperson Grievances and Personal Rights; are posted on the wall. Children are not restricted to make phones calls based on the court and or authorized representative. The staff room is available for the clients to make phones calls and the Phone Call Log is kept in the clients file.(page 2 of 3) LPA observed the child's Needs and Services plans kept in the client's chart; (filed electronic medical records). Some outside extracurricular activities and social events that take persons into public or crowded places have been restricted. Alternate activities have been implemented based the compliance of the client. Children are taken into the park, go hiking, and biking or have games within the facility. There were no deficiencies cited at this time. LPAs will return to the facility later to complete the inspection tool (Staff Records Reviews, Staff and Client interviews). LPA-Gray concluded the inspection and a copy of this report was left at the facility with the Program Administrator on 09/28/2021. (page 3 of 3)

met_with: ADMINISTRATOR