summary: Facility Evaluation

raw_content:
Narrative:
On September 6, 2024, at 9: AM, Licensing Program Analysts (LPAs) Jacob Salem and Abby Saeteurn conducted an unannounced visit to the above facility and met with Center for Positive Changes Amber Jansen, Chief Operations Officer (COO) for the purpose of conducting a post-licensing inspection. LPAs and COO toured the facility inside and out. The home is a one-story building with four bedrooms and two bathrooms which are set up as follows: · Bedroom #1 (Client) has two twin beds and sleeps one clients. · Bedroom #2 (Client) has two twin beds and will sleep two clients. · Bedroom #3 (Client) has one twin bed and sleeps one client. · Bedroom #4 (Client) has one twin bed and will sleep one client. · Kitchen and dining area, living room, large family room area and table, a laundry room, staff office, storage closet, backyard/patio area, and attached two car garage. The License, Emergency Disaster Plan, Personal Rights, and complaint procedures are posted outside the kitchen area of the home. The client bedrooms are arranged so that no more than two clients will share a room, no room commonly used for other purposes will be used as a bedroom, and no bedroom serves as a passageway to another room. There is adequate closet space for the clients' belongings. Client mattresses, blankets, pillows, and linens are clean and in good repair. There is a smoke detector in two bedrooms and a carbon monoxide located in the open family room area. The smoke detectors and the carbon monoxide detector were tested and are working properly. There are additional bath towels and basic toiletries located in a locked cupboard in the hallway area. The kitchen is clean and well maintained with adequate utensils, dishware, and appliances for food storage and preparation. The kitchen contains adequate perishable and non-perishable food supplies for clients present in the home. There are additional perishable food supplies located in the garage freezer. There is a trash can for storage of solid waste in the kitchen with a tight-fitting lid. Continued... ...CONTINUED The home's central air conditioning module is located in dining area and the home is kept at a comfortable temperature. There is a spacious living room area with a sofa chairs, TV, reading material, and recreational activities for clients to use for relaxation or visitation from family and friends. There is also space and recreational activities in the garage for visitation. The facility has supplies and appliances necessary for laundering clients' personal clothing. The home is well lit and passageways are free from obstructions. The backyard consists of a patio and yard area, and window screens around the facility were inspected and in good repair. A complete first aid kit is readily accessible and located in the staff office cabinet. Two fire extinguishers are present in the home and located in the kitchen and family room. They were observed to be recently inspected by the fire department. Staff stated there were no weapons/firearms in the home and harmful cleaning supplies are locked in the hallway closet and inaccessible to clients. Knives are locked in the staff office cabinet. There is no swimming pool. The backyard where clients have access to play is completely fenced. The facility has telephone service on the premises. The client's files are locked inside a cabinet in the staff office. Client files (C1 and C2) were reviewed and contained demographic information, intake records, needs and services plans, medication logs, and records of cash resources and personal property. The facility has a Emergency and Disaster Plan, which contains required procedures, such as provision of emergency power, storage and preservation of medications, and the location of utility shut off valves. Due to time constraints, the annual is being extended to conduct an inspection of the staff files and client interviews. Based on observations made during the inspection, there were no deficiencies cited at this time. An exit interview was conducted with Amber Jansen, Chief Operations Officer and a signed copy of this report was provided.

met_with: Amber Jansen, Chief Operations Officer


state: CA

facility_name: CENTER FOR POSITIVE CHANGES

summary: Facility Evaluation

raw_content:
Narrative:
On September 10, 2024 at 3: PM, Licensing Program Analyst (LPA) Jacob Salem arrived to the facility and met with Anthony Anders, Facility Manager. The purpose of this Case Management inspection is to conduct an post-licensing continuation from 9/6/2024. LPA reviewed five staff files (S1-S5) at the facility's corporate office the same day. The staff files have the required background information and health screenings, criminal record clearances, staff qualifications, and training requirements. LPA reviewed the emergency intervention plan at the facility, which contained all of the required information. LPA tested the water temperature in the two client bathrooms and measured the first bathroom's sink to run at 118.0 degrees F, and the second to be 118.8 degrees F. LPA conducted one client interview. Based on observations made during the inspection, there were no deficiencies cited at this time. An exit interview was conducted with Anthony Anders, Facility Manager and a signed copy of this report and LIC 811 were provided.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Anthony Anders, Facility Manager


facility_name: CENTER FOR POSITIVE CHANGES II

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews stated the police and paramedics arrived on site and transported C1 by ambulance. Confidential interviews stated the paramedics revived C1 by Narcan and C1 was released from the hospital the following day. Confidential interviews stated staff maintained supervision of C1 and acted appropriately however C1 brought fentanyl into the building and it was reported C1 unintentionally overdosed. Confidential interviews stated staff searched C1 following procedures when C1 was admitted to the facility however staff is limited in their search authority as a result of personal rights. Based on confidential interviews, the allegation that C1 overdosed while in care due to lack of supervision may have occurred, however are not supported or proven by evidence. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this signed report was emailed to Facility Manager Paul Kelley.

Investigation Findings:
13On August 18, 2022, at 1:30 p.m. Licensing Program Analyst (LPA) Marisol Lopez arrived at the facility unannounced and met with Facility Manager Paul Kelley of Center for Positive Changes II to discuss the investigative findings for the allegation noted above. On January 24, 2022, Community Care Licensing's (CCL) Investigations Branch Bureau, Investigator Annette Renquist was assigned the investigation. On 1/24/2022, Investigator Annette Renquist met with Program Representative Erica Williams to conduct an unannounced initial complaint investigation. The investigation consisted of confidential interviews with one administrator, four facility staff (S1 - S4), client #1 (C1), and review of incident reports and medical documents. On 01/21/2022, the Department received an allegation that Client #1 (C1) overdosed while in care due to lack of supervision. Confidential interviews reported C1 was in the bathroom when Staff#2 (S2) heard noises coming from the bathroom. Confidential interviews stated that after no response, Staff#2 (S2) was able to open the door to find C1 unresponsive and S2 started CPR, while Staff #1 (S1) called 911. (see continuation form LIC9099-C dated 08/18/22) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Marisol Lopez 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 08-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, METROPOLITAN DR. # FACILITY NAME: CENTER FOR POSITIVE CHANGES IIFACILITY NUMBER: VISIT DATE: 08/18/2022

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

report_type: Complaint Investigation

met_with: Paul Kelley

complaint_status: unsubstantiated


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
...CONTINUED Conflicting confidential interviews indicate that clients have not been seen using illegal drugs at the facility and that staff use effective search procedures after clients return from being absent without permission. Confidential interviews indicate that staff conduct frequent room checks and search for contraband while cleaning clients' bedrooms. A record review of staff logs on 02/14/2024 reveals that regular room checks were conducted, and no incidents of drug use were reported. SI Sun conducted a walkthrough of the facility and did not observe any contraband, abnormal smells, or other evidence of drug use. Based on confidential interviews, records reviewed, and observations, the allegation that due to a lack of supervision, clients (unnamed) are using illegal drugs on facility premises is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Paul Kelley, Administrator and a copy of this report and appeal rights were provided and explained.

Investigation Findings:
13On May 31, 2024 at 1: PM, Licensing Program Analysts (LPAs) Jacob Salem and Abby Saeteurn met with Paul Kelley, Administrator of Center for Positive Changes II, to deliver the finding for the above-stated allegation. The investigation was conducted by Special Investigator (SI) Ge Sun, who interviewed two Probation Officers, staff (S1-S4), former staff (S5), and clients (C1-C4). SI attempted to interview a former client (C5) but was unable to interview due to the client refusing and later not being present at their current placement. Pertinent records were obtained and reviewed. On February 16, 2024, Community Care Licensing (CCL) received an allegation that due to a lack of supervision, clients (unnamed) were using illegal drugs on facility premises. Confidential interviews reported on the night of 02/14/2024, clients used methamphetamines and marijuana in the facility while staff were in the other room. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Jacob Salem 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Center for Positive Changes Iifacility Number: Visit Date: 05/31/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...CONTINUED Conflicting confidential interviews indicate that clients have not been seen using illegal drugs at the facility and that staff use effective search procedures after clients return from being absent without permission. Confidential interviews indicate that staff conduct frequent room checks and search for contraband while cleaning clients' bedrooms. A record review of staff logs on 02/14/2024 reveals that regular room checks were conducted, and no incidents of drug use were reported. SI Sun conducted a walkthrough of the facility and did not observe any contraband, abnormal smells, or other evidence of drug use. Based on confidential interviews, records reviewed, and observations, the allegation that due to a lack of supervision, clients (unnamed) are using illegal drugs on facility premises is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Paul Kelley, Administrator and a copy of this report and appeal rights were provided and explained. SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of 2

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0

met_with: Paul Kelley, Administrator


raw_content:
Narrative:
...CONTINUED Confidential interviews indicated that clients (C2-C4) were drinking with non-client youths in the neighborhood on multiple occasions but were out of sight of the facility. Confidential interviews indicated that staff follow clients to the end of the street if they observe clients leaving the facility without permission (going AWOL), but then return to the facility to maintain staffing levels and file a missing person's report. Confidential interviews indicated that the police were notified once neighbors and staff became aware the clients (C2-C4) were loitering and using alcohol in the neighborhood. Conflicting confidential interviews and records reviewed indicated that clients go AWOL frequently and return appearing under the influence, despite the discouragement by staff and disciplinary consequences that clients receive. Confidential interviews indicated that staff also conduct "perimeter checks" when clients return from being AWOL by walking around the facility to prevent prohibited behavior and contraband on facility premises. Confidential interviews indicated that staff conduct searches in a manner that does not violate clients' personal rights, and, as a result, clients are able to sneak contraband into the home. Confidential interviews and records reviewed indicated that staff frequently find and dispose of alcohol and other substances hidden in the clients' bedrooms. Confidential interviews indicated that staff conduct regular room checks with clients present, especially when there is suspicion of substance use. Confidential interviews indicated that staff conduct room checks at least every hour, and that some shifts "forget" to check on clients. Conflicting confidential interviews indicated that staff are "constantly" checking on clients "at least every fifteen minutes" when they are in their bedrooms. Confidential interviews indicated that clients seen during room checks using substances are asked to turn the substances in and, if they refuse, receive appropriate consequences. Confidential interviews indicated that clients are never at the facility without staff. Based on conflicting confidential interviews and records reviewed the allegations that minors use illegal substances and drink alcohol on the premises, and that staff do not provide adequate supervision to minors in care are unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Kendrick Johnson, Facility Manager and a copy of this report and appeal rights were provided and explained.

Investigation Findings:
13On November 8, 2024, at 9: AM, Licensing Program Analyst (LPA) Jacob Salem met with Kendrick Johnson, Facility Manager of Center for Positive Changes II to deliver the finding for the above-stated allegations. LPA Salem initiated a complaint inspection at the facility on 5/31/2024 at 12: PM and no immediate deficiencies were observed. During the investigation, LPA Salem interviewed Staff (S1-S3), Clients (C1-C7), County Social Worker (CSW), and a Neighbor. Pertinent records were obtained and reviewed. On May 21, 2024, Community Care Licensing (CCL) received an allegation that minors (unnamed) use illegal substances and drink alcohol on the premises, and that staff (unnamed) do not provide adequate supervision to minors (unnamed) in care. It was reported that several minors were in front of the home drinking alcohol, as well as knocking on neighbors' doors and looking in neighbors' windows. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Center for Positive Changes Iifacility Number: Visit Date: 11/08/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...CONTINUED Confidential interviews indicated that clients (C2-C4) were drinking with non-client youths in the neighborhood on multiple occasions but were out of sight of the facility. Confidential interviews indicated that staff follow clients to the end of the street if they observe clients leaving the facility without permission (going AWOL), but then return to the facility to maintain staffing levels and file a missing person's report. Confidential interviews indicated that the police were notified once neighbors and staff became aware the clients (C2-C4) were loitering and using alcohol in the neighborhood. Conflicting confidential interviews and records reviewed indicated that clients go AWOL frequently and return appearing under the influence, despite the discouragement by staff and disciplinary consequences that clients receive. Confidential interviews indicated that staff also conduct "perimeter checks" when clients return from being AWOL by walking around the facility to prevent prohibited behavior and contraband on facility premises. Confidential interviews indicated that staff conduct searches in a manner that does not violate clients' personal rights, and, as a result, clients are able to sneak contraband into the home. Confidential interviews and records reviewed indicated that staff frequently find and dispose of alcohol and other substances hidden in the clients' bedrooms. Confidential interviews indicated that staff conduct regular room checks with clients present, especially when there is suspicion of substance use. Confidential interviews indicated that staff conduct room checks at least every hour, and that some shifts "forget" to check on clients. Conflicting confidential interviews indicated that staff are "constantly" checking on clients "at least every fifteen minutes" when they are in their bedrooms. Confidential interviews indicated that clients seen during room checks using substances are asked to turn the substances in and, if they refuse, receive appropriate consequences. Confidential interviews indicated that clients are never at the facility without staff. Based on conflicting confidential interviews and records reviewed the allegations that minors use illegal substances and drink alcohol on the premises, and that staff do not provide adequate supervision to minors in care are unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Kendrick Johnson, Facility Manager and a copy of this report and appeal rights were provided and explained. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of 4

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0

met_with: Kendrick Johnson, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 06/09/2021 at 09: AM, Licensing Program Analyst (LPA) Marisol Lopez and LPA Danielle Garcia conducted an unannounced required annual inspection of the facility and met with Program Manager (PM) Paul Kelley. LPA's and PM inspected the facility inside and out. The facility is a one-story residence with three bedrooms, two bathrooms, dining room, living room, family room, kitchen, laundry room, and therapy room. The facility has been operating with the capacity of six male from ages 13 years old to 17 years old and non-minor dependents. The bedrooms are set up as follows: Bedroom #1 is occupied by two clients; two twin beds, all required linen, mattress in good condition. Bedroom #2 is occupied by two clients; two twin beds, all required linen, mattress in good condition and share a bathroom. Bedroom #3 is occupied by two clients; two twin beds, all required linen, mattress in good condition and a shared bathroom. Bedroom #1 and Bedroom #2 share a bathroom. All bedrooms contained adequate shelf and closet space for resident's belongings. The bathrooms were clean and in good repair. LPA tested the hot water temperature in clients' bathroom which read 113 degrees F, which is in range of 105- F. Office supplies, knives, medication, medication logs, first aid kit and clients' files are kept in the locked therapy room. The medication is locked in a locked box inside a cabinet inside the therapy room. All hazardous items were made inaccessible to areas where residents do not have access. Cleansers/chemicals are located in the locked garage inside a cabinet. The facility's smoke detectors in the hallways and 3 bedrooms were checked and were operable. The carbon monoxide detector is located in the hallway across from Bedroom #1 was tested and in operable condition. LPA's observed a sufficient supply of 7-day non-perishable food for six residents and a sufficient supply of 2-day perishable food in the kitchen. LPA's observed the kitchen to be clean, sanitary and in good repair. The facility outside grounds were inspected. LPA's observed the outside ground to be clean and maintained. There was an ample amount of recreational and leisure supplies such as books, games, gym and television available for client use. Emergency exits were free from obstruction. The following required posted items were observed and accessible to children: Ombudsman and Foster Youth Bill of Rights, Grievance Procedures, the updated Personal Rights, Visitation policies, house rules, current menu and neighborhood complaint. Licensee has obtained National Accreditation through CARF and the Accreditation is valid through August 2022. LPA's discussed the following with the Administrator: Incident reporting, including incidents related to Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. Personnel Files are maintained off-site and transported to LPA's within a reasonable time. All staff who work at the facility have Department of Justice and Child Abuse Clearance index check clearances. A review of client records was also completed on this date including the Medication Administration Record (See Confidential Name List- LIC 811 dated on June 09, 2021). Personnel files were reviewed to ensure they contained all required documentation. Children and staff records are organized. Staff's CPR and First Aid card were current. Child's records contain original needs and services plan signed by the child and their authorized rep. Child's records contain authorization for emergency medical care signed by each child's authorized rep. Facility personnel meet staff training requirements. Appropriate staff/client ratios were verified during this inspection. Based on observations made during the inspection, no deficiencies observed during today's visit. An exit interview was conducted and this report was reviewed with Program Manager Paul Kelley and a copy of this report was provided.

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
On August 19, 2021 at 10: AM, Licensing Program Analysts (LPA) Cindy Hamilton conducted an unannounced SB Psychotropic Medication Inspection. During the inspection, LPA Hamilton met with Paul Kelley Facility Manager and Kendrick Johnson, Assistant Facility Manager and inspected the facility inside and out. LPA reviewed 2 client psychotropic records at 11: AM. LPA reviewed three staff personnel files at the facility at 12: PM. LPA began two staff interviews at 12: PM LPA did not condutct client interviews due to Client #1 (C1) was attending school at time of inspection and Client #2 (C2) was Absent With Out Leave (AWOL) from the facility. No deficiencies were being cited at this time. LPA conducted exit interview with Paul Kelley, Facility Manager. LPA provided the Summary Report and Appeal Rights to Paul Kelley upon completion.

met_with: Paul Kelley, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Veronica Whitaker conducted a case management inspection April 26, 2022 at 11: AM based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 11 out of Direct Care Staff and 6 out of 6 youth files were reviewed. 4 out of Direct Care Staff and 1 out of 6 youth were interviewed. (See the Confidential Names List, LIC 811, dated April 26, 2022). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth case plans, quarterly assessments, and crisis intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Veronica Whitaker observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Deanna Mellos, Director.

met_with: Deanna Mellos, Director


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Latricia Rogers conducted a case management inspection on June 14,2023 based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 4 out of Direct Care Staff and 5 out of 5 youth files were reviewed. 2 out of Direct Care Staff and 2 out of 5 youth were interviewed. (See the Confidential Names List, LIC 811, June 14,2023.) The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth case plan and, quarterly assessments, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Rogers observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Paul Kelley- Administrator.

met_with: Paul Kelley- Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On November 2, 2023, at 8:15a.m., Licensing Program Analyst (LPA) Jacob Salem arrived at the above facility for the purpose of conducted an unannounced annual inspection. LPA met with administrator Paul Kelley and explained the purpose of the visit. LPA began the inspection by conducting two client interviews and two staff interviews. LPA inspected the facility's physical plant. The facility is a one-story residence with a garage and back yard. Inside the residence there are three bedrooms, two bathrooms, kitchen, staff room, locked office, living room, and laundry room. There are currently six clients residing at this facility with no more than two clients sharing a bedroom. All three bedrooms had mattresses and pillows in good condition, clean sheets and blankets, and closet or dresser space with clothing. LPA observed extra linens and towels in the closet, which were clean and in good condition. Both bathrooms were clean and sanitary with a working shower, sink, and toilet. Additionally, the sink in each bathroom fell within the regulations for water temperature: 116.2- and 107.6-degrees Fahrenheit. LPA observed the kitchen to be clean and sanitary. LPA observed the refrigerator, pantry, and chest freezer to be fully stocked, exceeding the requirement for food supplies. Finally, LPA observed a menu for the week posted on the refrigerator door consisting of three meals. Adjacent to the kitchen area, the living room prominently displays the facility license, grievance procedures, foster child bill of rights, facility sketch, and emergency disaster plan. LPA observed the living room to be clean and contain a large couch and TV. ...CONTINUED The cabinet in the office room is locked and contains sharps, medication, medication logs, and a complete first aid kit. The facility contains multiple carbon monoxide and smoke detectors, all of which were tested to be operable. The laundry rooms consist of a washer and dryer machine, and all detergents, disinfectants, and cleaning solutions are made inaccessible and locked in a closet in the staff room. The backyard consists of a patio, ping-pong table, and exercise area. LPA observed no safety hazards in the backyard. Finally, LPA tested the seat belts and blinkers in the car used to transport clients, all of which were operable. Client files were provided to LPA for review, and all of which contained the required paperwork, including signed admission agreement, signed needs and services plans, and records of cash resources and personal property. Due to time constraints, the annual is being extended to conduct an inspection of the staff files. Based on observations made during the inspection, there were no deficiencies cited at this time. An exit interview was conducted with Administrator Kelly and a signed copy of this report was provided.


facility_name: CFLC-HEMET HOUSE

raw_content:
Narrative:
Confidential interviews revealed that the staff were not told about the inappropriate behaviors when they occurred. Based on confidential interviews, allegation that due to lack of supervision clients were able to have inappropriate sexual interactions on at least one occasion, may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. No deficiencies were cited. An exit interview was completed and a copy of this report, LIC811 and appeal rights were explained and handed to Rafaela Aguilar.

Investigation Findings:
13On July 16 , 2021 at 11: AM, Licensing Program Analyst (LPA) Anastasia Flores met with (STRTP) CFLC Hemet House Administrator, Rafaela Aguilar, to deliver the findings of the above allegation. On May 7, 2021 at 12: PM, LPA conducted an inspection of the facility and no health and safety inspec were noted. Copies of STRTP staff roster, STRTP client roster, Needs and services plan for client #2 (C2) and Incident report date 4/25/21 were obtained. Interviews were conducted with five out of six clients, (C2, C3, C4, C5, C6) Riverside County Out of Homes Investigator (OHI) and STRTP Administrator (ADM). On April 29, 2021 this agency received allegation that due to lack of supervision clients were able to have inappropriate sexual interactions. Confidential interviews disclosed that C2 and C4 engaged in inappropriate behaviors on at least one occasion in the room. Interview with ADM disclosed the staff will check on the clients every 15 minutes at night and are required to complete visual checks and log into the daily communication log when conducted. Interview with OHI disclosed no concerns with the care and supervision of the STRTP. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Christina Barnes LICENSING EVALUATOR NAME: Anastasia Flores 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: CFLC-HEMET HOUSEFACILITY NUMBER: VISIT DATE: 07/16/2021

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

met_with: Rafaela Aguilar


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
(Continued) On May 6, 2022, the Department received a complaint that alleged staff did not ensure minor attended scheduled medical appointment. Specifically, it was alleged that C1 did not receive medical care after a procedure and there were more service refusal documents than appointments made for C1. Regarding the allegation staff did not ensure C1 attended scheduled medical appointment, confidential interviews and documentation verify staff made multiple attempts to encourage C1 to attend C1's scheduled appointments. Confidential interviews and documentation revealed four scheduled appointments were refused by C1 after various prompts and encouragement were provided. Additionally, confidential interviews and documents revealed follow up regarding the procedure was indicated if there were specific signs and symptoms, none of which were observed by staff or communicated by C1. Confidential interviews indicated six weeks after the procedure, C1 requested, and staff ensured C1 attended an appointment at urgent care where treatment was provided. Other information states the allegation occurred. Based on confidential interviews, the allegations that staff did not ensure C1 attended scheduled medical appointment may have occurred, however it is not supported, or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, a copy of this report, and LIC 811 was provided to the facility.

Investigation Findings:
13On May 5, 2023, Licensing Program Analyst (LPA) Val Wilson met with CFLC Hemet House, Short Term Residential Therapeutic Program (STRTP) Assistant Administrato, Lizeth Ruvalcaba, to deliver the investigative finding for the above stated (See LIC Confidential Name List). LPA inspected the facility, on May 10, 2022, at 2:30PM, reviewed facility files and interviewed staff and two clients. LPA also obtained and reviewed copies of the Register of Facility Clients, LIC 500, Placement Agreement, special Incident report (SIR) for medical refusals, urgent care receipt, medical refusal notes, therapist notes, medication administration records (MARs) and Innercare-CVS scheduled appointments. During the investigation, confidential interviews were conducted by LPA Wilson with administrator (ADM), therapist (THR), licensed vocational nurse (LVN), Staff 1 (S1), Staff 2 (S2), Staff 3 (S3), mental health director (MHD), Client 1 (C1) and Client 2(C2), and STRTP director (DIR). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Valerie 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 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: CFLC-HEMET HOUSEFACILITY NUMBER: VISIT DATE: 05/05/2023

met_with: Lizeth Ruvalcaba


raw_content:
Narrative:
*****Continued***** ensure that minors in care are receiving services as needed, and staff did not safeguard personal property of minor in care. Specifically, it was alleged that the ADM inhibits the BHS the ability to provide trauma informed care to Y1 and Y2. Additionally, ADM and S2 make inappropriate comments to Y1 and does not safeguard Y1's cash. Regarding the allegation that ADM use inappropriate forms of discipline with Y1 and Y2 in care, confidential interviews revealed discipline consists of loss of TV, video games, and special outings. In addition to reasonable and prudent parenting, documentation and interviews noted needs and services plans are agreed to by the youth and the multi-disciplinary team to address individualized needs and staff coach the youth as needed when they are not following their objectives. Other information states the allegation occurred. Regarding the allegation that ADM emotionally abused Y1 in care, confidential interviews deny abuse or neglect of any kind. Interviews revealed the STRTP staff work cohesively with each youth to learn daily living life skills for better mental health outcomes. Youth are spoken to with dignity and respect. Other information states the allegation occurred. Regarding the allegation that ADM does not ensure that Y1 and Y2 are receiving services as needed in care, confidential interviews revealed the STRTP utilizes a strength based and trauma Informed approach while working within a multi-disciplinary team. Other information states the allegation occurred. Based on confidential interviews, the allegations that ADM uses inappropriate forms of discipline with Y1 and Y2 in care, ADM emotionally abused Y1 in care, ADM does not ensure that Y1 and Y2 are receiving services as needed in care, and ADM did not safeguard personal property of Y1 in care, may or may not have occurred; However, they are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, a copy of this report, and LIC 811 was provided to the facility representative.

Investigation Findings:
13On March 14, 2024, at 3: PM, Licensing Program Analysts (LPA), Val Wilson, met with Assistant Administrator/Facility Manager, Yolanda Valdez, at CFLC Hemet Ranch Short Term Residential Therapeutic Program (STRTP), to issue the findings for the above stated allegations involving the STRTP and youth listed on the confidential Names List, LIC 811, dated March 14, 2024. On March 23, 2023, at 2: PM, LPA Wilson arrived at the STRTP and a safety inspection was completed without any health and safety concerns observed. LPA Wilson reviewed client files, facility documents, and obtained copies of the client roster, LIC 500, needs and services plans, job description, and staff files. During the investigation, interviews were conducted with youth 1 (Y1), youth 2 (Y2), youth 3 (Y3), youth 4 (Y4), youth 5 (Y5), youth 6 (Y6), youth 7 (Y7), staff 1 (S1), staff 2 (S2), staff 3 (S3), staff 4 (S4), therapist (THR), behavioral health specialist (BHS), program director (PD), mental health director (MHD), and administrator (ADM). On March 17, 2023, the Department received a complaint that alleged a staff use inappropriate forms of discipline with minors in care, staff emotionally abused minor in care, staff do not *R- 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: CFLC-HEMET HOUSEFACILITY NUMBER: VISIT DATE: 03/15/2024

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

met_with: Yolanda Valdez


raw_content:
Narrative:
Confidential interviews stated that staff does not want any of the clients on a 5150 hold as it is traumatizing therefore staff wouldn't make inappropriate comments like that. Other confidential interview maintained that staff uses inappropriate comments sometimes when dealing with behaviors. Regarding the allegation that staff did not ensure the minors attend scheduled court date, confidential interviews stated that when clients don't want to attend a court date, staff encourages them to go. Other confidential interviews stated that court dates are scheduled in the office calendar, so all staff know when a court date is coming up. Additionally, confidential interviews stated clients will always have a ride to any court date, however, LPA was unable to verify if the information was true. Based on confidential interviews and a review of pertinent documents, the allegations that staff make inappropriate comments towards a minor and staff did not ensure the minors attend scheduled court date, may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. 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 assistant administrator Patricia Parker.

Investigation Findings:
13On September 20, 2024, at 11: AM, Licensing Program Analysts (LPA) Maryjane Perez conducted an unannounced visit at California Family Life Center (CFLC) - Hemet House Short Term Residential Therapeutic Program (STRTP) and met with Assistant Administrator Patricia Parker to deliver the finding for the above stated allegations. On July 22, 2024, Community Care Licensing received complaint allegations that staff make inappropriate comments towards a minor and staff did not ensure the minors attend scheduled court date. On August 1st, 2024, LPA's M. Perez and Joon Choi conducted a health and safety inspection of the facility, and no immediate health and safety hazards were observed. LPAs also obtained pertinent documentation and interviewed 3 clients (C1, C2, C3) and 4 staff (S1, S2, S3, S4). In regard to the allegation that staff made inappropriate comments towards a minor, it was specifically reported that staff told minor that the minor "should go to a mental health place and kill themselves". During investigation confidential interviews stated that staff don't use negative language or say inappropriate things. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: MaryJane Perez 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 RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: CFLC-HEMET HOUSEFACILITY NUMBER: VISIT DATE: 09/20/2024

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

met_with: Patricia Parker- Assistant administrator


raw_content:
Narrative:
Regarding the allegation that staff did not prevent C1, C2 from engaging in inappropriate behaviors. A confidential interview stated that C1 and C2 did not share a room. The confidential interview added that staff was always by the door verbally prompting C2 not to go to C1's room. Another confidential interview stated staff did not do enough to stop C2 from going into C1's. The confidential interview believed staff didn't handle the incident appropriately. Additional confidential interview stated two staff were assigned to supervise both clients. The additional confidential interview added that staff made sure nothing inappropriate was taking place when C2 was in C1's room, staff stood by all the time. Based on confidential interviews, the allegation that staff did not prevent C1, C2 from engaging in inappropriate behaviors may have occurred, however, there was not a preponderance of evidence to support the alleged violation. Therefore, this allegation is unsubstantiated at this time. A copy of this report, LIC 811 and the appeal right was reviewed and provided to STRTP representative.

Investigation Findings:
13On February 27, 2025, Licensing Program Analyst (LPA) Babatunde Aborchie arrived at CFLC- Hemet House, Short Term Therapeutic Residential Program (STRTP) to deliver investigative finding involving the STRTP. LPA met with Sheila Stephenson, Director. On April 9, 2024, a complaint report was referred to Community Care Licensing (CCL) alleging staff did not prevent minors from engaging in inappropriate behaviors. On June 11, 2024, LPA B. Aborchie arrived at the STRTP to initiate investigation of the above allegation and conducted a safety inspection. There were no safety issues observed. During investigation, LPA interviewed client 1, 2, 3, 4 (C1, C2, C3 and C4), staff (S1) and administrator (A1). LPA was unable to interview County Social Worker (CSW). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Babatunde Aborchie 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: CFLC-HEMET HOUSEFACILITY NUMBER: VISIT DATE: 02/27/2025

met_with: Sheila Stephenson


raw_content:
Narrative:
Regarding the allegation that staff yell profanities towards the minors, a confidential interview stated staff did not use inappropriate words towards C1. The confidential interview added that staff were always professional with C1. Another confidential interview stated staff was always nice and easy to communicate with. The confidential interview added C1 may use profanity, but staff did not. Additional confidential interview stated all facility staff were made aware of the use of proper communication with all clients. The additional interview was not sure if staff used profanity to communicate with C1, but staff was always calm and helpful when C1 was unhappy. Regarding the allegation that staff were threatening C1. A confidential interview reported that C1 had not been threatened by staff while in care. The confidential interview added that staff were very helpful and caring. Another confidential interview stated C1 felt safe in the home. The confidential interview added no staff had been heard threatening C1 while in care. Additional confidential interview stated there had not been any reports directed to client safety in the home. The additional confidential interview felt C1 was safe while in care. LPA was unable to interview C1 due to no contact information found. Based on confidential interviews, the allegations that staff yell profanities towards C1, staff are threatening the C1 may have occurred, however, there was not a preponderance of evidence to support the alleged violation. Therefore, this allegation is unsubstantiated at this time. A copy of this report, LIC 811 and the appeal right was reviewed and provided to STRTP representative.

Investigation Findings:
13On February 27, 2025, Licensing Program Analyst (LPA) Babatunde Aborchie arrived at CFLC- Hemet House, Short Term Therapeutic Residential Program (STRTP) to deliver investigative finding involving the STRTP. LPA met with Sheila Stephenson, Director. On May 30, 2024, a complaint report was referred to Community Care Licensing (CCL) alleging staff yell profanities towards the minors and staff are threatening the minors. On June 6, 2024, (LPA) Babatunde Aborchie arrived at the STRTP to initiate investigation of the above allegations and conducted a safety inspection. There were no safety issues observed. During investigation, LPA interviewed client 2, 3 (C2 and C3), staff 1, 2 (S1, S2) and Administrator (A1). LPA was unable to interview County Social Worker (CSW). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Babatunde Aborchie 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: CFLC-HEMET HOUSEFACILITY NUMBER: VISIT DATE: 02/27/2025


raw_content:
Narrative:
It was further reported that C1 did not feel safe at the facility and ran away. Confidential interviews reported that other minors in the facility were bullying and threatening physical harm to C1. Other confidential interviews denied that the other minors in the facility were bullying or threatening C1. Other confidential interviews disclosed facility staff (name not provided) was verbally threatening C1. Other confidential interviews reported that no facility staff ever threatened C1. Confidential interviews reported that C1 had anxiety about attending school and resulting C1 to run away from placement. LPA received inconsistent information. Based on confidential interviews, the allegations that staff do not prevent minors from threatening other minor in care and staff do not prevent minors from bullying other minor while in care may have occurred or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted. A copy of this report (LIC 9099) and appeal rights were explained and given to Assistant Administrator Patricia Parker.

Investigation Findings:
13On 03/21/2025 at 11: AM, Licensing Program Analyst (LPA) Joon Choi conducted an unannounced visit to California Family Life Center (CFLC) Hemet House Short Term Residential Treatment Program (STRTP) and met with Assistant Administrator Patricia Parker, to deliver the investigative finding for the allegations listed above. On 06/05/2024, Community Care Licensing received allegations staff do not prevent minors from threatening other minor in care and staff do not prevent minors from bullying other minor while in care. On 06/06/2024, LPA Babatunde Aborchie conducted a health and safety inspection at the STRTP, and no immediate health and safety hazards were observed. During the investigation, LPA Choi obtained documents pertinent to the investigation and in addition, LPA Choi interviewed client 1 (C1) and staff 1 and 2 (S1, S2). In regard to the allegations that staff (names not provided) do not prevent minors (names not provided) from threatening other minor (C1) in care and staff (names not provided) do not prevent minors (names not provided) from bullying other minor (C1) while in care; it was reported that C1 was being "bullied and threatened" by other children in the facility. CONTINUED ON THE NEXT PAGE UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Joon R Choi 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 RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: CFLC-HEMET HOUSEFACILITY NUMBER: VISIT DATE: 03/21/2025

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

met_with: Patricia Parker, Assistant Administrator


raw_content:
Narrative:
Confidential interviews continued stating that staff conduct room checks every 10-15 minutes and supervise clients in common areas. Another confidential interview stated that if clients report an inappropriate behavior about another client, staff don't do anything about it. LPA received a conflicting information. Based on confidential interviews and a review of pertinent documents, the allegation that facility staff did not prevent C1 and C2 from engaging in inappropriate behaviors with each other may have happened or is valid but there is not a preponderance of the evidence to prove that the alleged violation occurred. 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 facility manager Patricia Parker.

Investigation Findings:
13On May 23rd, 2025, Licensing Program Analyst (LPA) Maryjane Perez made an unannounced visit to CFLC- Hemet House and met with facility manager Patricia Parker to deliver the finding for the above stated allegation involving facility staff and clients listed on the Confidential Names (LIC 811). On 12/30/2024, Community Care Licensing received complaint allegation that facility staff did not prevent youth(s) from engaging in inappropriate behaviors with each other. On 01/03/ LPA M. Perez conducted a health and safety inspection of the facility, and no hazards were observed. Lpa M. Perez interviewed staff 1 (S1), staff 2 (S2), staff 3 (S3), staff 4 (S4), client 1 (C1), client 2 (C2), client 3 (C3) and client 4 (C4). During investigations, confidential interviews reported that when clients show signs of inappropriate behaviors, they redirect the client and switch rooms to avoid potential reoccurring inappropriate behaviors. Other confidential interviews stated they have not observed any inappropriate behaviors between the clients. While another confidential interview stated that one client had been kissing another client. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: MaryJane Perez 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 RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: CFLC-HEMET HOUSEFACILITY NUMBER: VISIT DATE: 05/23/2025

met_with: Facility Manager- Patricia Parker


raw_content:
Narrative:
During the investigation, confidential interviews indicated that facility staff observed a bruise on C1 and documented and reported the details of the incident to appropriate representatives. Other confidential interviews reported that C1 and C2 often engaged in skylarking behaviors in the facility and staff redirected the behaviors consistently. LPA received inconsistent information. Pertaining to the allegation that staff did not address a child's behavior resulting in children participating in CSEC activity, it was specifically reported that C1 has high-risk behaviors, will often AWOL from placement, and will meet up with unknown adults. During the investigation, confidential interviews reported that C1 began to leave the facility without authorization and engage in inappropriate activities after a few weeks of placement. Other confidential interviews indicated that a Child and Family Team (CFT) meeting was conducted, as well as a crisis intervention plan to address the concerns. LPA received conflicting information. Based on confidential interviews and evidence obtained, the allegations that C1 sustained an injury due to staff neglect or physical abuse and that staff did not address C1's behavior resulting in children participating in CSEC activity may have occurred or may be valid; however, there is not a preponderance of evidence to support that a violation occurred. Therefore, the allegations are determined to be unsubstantiated at this time. An exit interview was conducted, and a copy of this report, along with appeal rights, was provided to the facility administrator, Lizeth Ruvalcaba.

Investigation Findings:
13On April 23rd, 2026 at 12:10PM, Licensing Program Analyst (LPA) Claudia Aguilera arrived at CFLC-Hemet House STRTP and met with the facility Administrator Lizeth Ruvalcaba to deliver the finding regarding the above-stated allegations. On 01/28/2026, Community Care Licensing received a complaint alleging that a child sustained an injury due to staff neglect or physical abuse and that staff did not address child's behavior resulting in children participating in CSEC activity. On 02/03/2026, LPA C. Aguilera initiated the investigation and conducted a health and safety inspection; no immediate deficiencies were observed. In addition, LPA C. Aguilera interviewed four staff (S1, S2, S3, S4) and four clients (C1-C4). Regarding the allegation that a child sustained an injury due to staff neglect or physical abuse, it was specifically reported that C1 had a bruise on their left upper arm. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Claudia Aguilera 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 RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: CFLC-HEMET HOUSEFACILITY NUMBER: VISIT DATE: 04/23/2026

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

met_with: Administrator, Lizeth Ruvalcaba


raw_content:
Narrative:
In regard to the allegation that staff does not ensure minor attends school, it was specifically reported that C1 does not attend school. During the investigation, confidential interviews reported that C1 declined to attend school. Other confidential interviews indicated that facility staff encourage clients to attend school and facility staff provide transportation when clients agree to attend school. LPA received conflicting information. Based on confidential interviews and evidence obtained, the allegations that staff does not ensure C1 does not have access to drugs and that staff does not ensure C1 attends school may have occurred or may be valid; however, there is not a preponderance of evidence to support that a violation occurred. Therefore, the allegations are determined to be unsubstantiated at this time. An exit interview was conducted, and a copy of this report, along with appeal rights, was provided to the facility administrator Lizeth Ruvalcaba.

Investigation Findings:
13On April 23rd, 2026 at 12:31PM, Licensing Program Analyst (LPA) Claudia Aguilera arrived at CFLC-Hemet House STRTP and met with the facility administrator or designee to deliver the findings regarding the above-stated allegations. On 01/30/2026, Community Care Licensing received complaint allegations that staff does not ensure minor does not have access to drugs and that staff does not ensure minor attends school. On 02/03/2026, LPA C. Aguilera initiated the investigation and conducted a health and safety inspection; no immediate deficiencies were observed. In addition, LPA C. Aguilera interviewed four staff (S1, S2, S3, S4) and three clients (C1-C3). Regarding the allegation staff does not ensure minor does not have access to drugs, it was specifically reported that C1 was using drugs. During the investigation, confidential interviews indicated that facility staff conduct a "shake out" upon a client's return from an unauthorized absence to prevent clients from bringing contraband into the facility. Other confidential interviews revealed that clients had drug paraphernalia in their possession that was confiscated by facility staff. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Claudia Aguilera 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 RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: CFLC-HEMET HOUSEFACILITY NUMBER: VISIT DATE: 04/23/2026

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


facility_name: CFLC-HEMET RANCH

raw_content:
Narrative:
LPA observed during inspection the knives behind two locked doors and the staff are diligent in only taking them out when able to supervise the use. Other confidential interviews denied the staff seem to be capable of handling incidents when necessary but there has been a lot of staff that have left the STRTP. Based on confidential interviews and record review, the allegation that facility staff were not adequately trained to handle client #1(C1) when C1 showed threatening behaviors may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. No deficiencies were cited. An exit interview was completed and a copy of this report, LIC811 and appeal rights were explained and handed to Anel Garcia.

Investigation Findings:
13On July 16 , 2021 at 10: AM, Licensing Program Analyst (LPA) Anastasia Flores met with (STRTP) CFLC Hemet Ranch Assistant Administrator, Anel Garcia to deliver the findings of the above stated allegation. On April 1, 2021 at 1: PM, LPA conducted a virtual inspection of the STRTP due to COVID and no health or safety hazards were noted. Copies of Special Incident Report (SIR) for client #1, #2 (C1, C2), Needs and service plan for C1, STRTP client roster, staff contact information were obtained. LPA conducted interviews with two out of four clients, three staff and probation officer for C2. LPA's attempts to contact C1, C2 was unsuccessful. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Christina Barnes LICENSING EVALUATOR NAME: Anastasia Flores 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: CFLC-HEMET RANCHFACILITY NUMBER: VISIT DATE: 07/16/2021

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

met_with: Anel Garcia


raw_content:
Narrative:
Other confidential interviews disclosed that C1 often blames things on the staff when asked to complete a non-preferred task. Interview with S1 disclosed that C1 was doing well when first arrived, communicates well and was a leader in the STRTP until the past month. Based on confidential interviews and record review, the allegation that C1 was emotionally abused by STRTP staff may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. No deficiencies were cited. An exit interview was completed and a copy of this report, LIC811 and appeal rights were explained and handed to Reyna Corona

Investigation Findings:
13On October 29, 2021 at 2: PM, Licensing Program Analyst (LPA) Anastasia Flores met with CFLC Hemet Ranch (STRTP) Administrator, Reyna Corona to deliver the finding of the above allegation. On July 16, 2021 at 09: AM, LPA conducted an inspection of the STRTP and no health or safety hazards were noted. Copies of staff roster, client roster, daily level system for Client #1, (C1) dated 7/07/21 through 7/13/21 and 3/17/21 through 3/23/21, STRTP Level system performance objectives and Child and Family Team meeting plan for C1 were obtained. Interviews were conducted with client #1, #2, #3 (C1, C2, C3) and staff #1, #2 (S1, S2). LPA's attempts to contact Orange County Social Worker (CSW) was unsuccessful. On July 7, 2021 this agency received allegation that client#1 (C1) was emotionally abused by STRTP staff. Confidential interviews disclosed that C1 is being used as a scapegoat. Other confidential interviews revealed that all clients are treated fairly and the staff try to help the clients with client needs. Confidential interviews disclosed the staff treat C1 differently than the other clients in the STRTP, telling C1 that C1 should be a role model to the other two clients in the STRTP instead of behaving badly. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Christina Barnes LICENSING EVALUATOR NAME: Anastasia Flores 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: CFLC-HEMET RANCHFACILITY NUMBER: VISIT DATE: 10/29/2021

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

met_with: Reyna Corona


raw_content:
Narrative:
C1 and C2 are not allowed to talk to each other. During confidential interviews it was revealed that the facility staff are the ones that determine what discipline measures should be taken and it is often discussed between the Facility Administrator and Program Coach. Additional confidential interviews revealed that the discipline issued depends on the incident and the age of the clients involved. Additionally, it was revealed during confidential interviews that the facility has house rules in place that state clients are not allowed to go on the different halls of the facility if their bedroom is not on that hall. It was also reported during confidential interviews that C2 was specifically told that they were not allowed to go on the hall of C1 because C2 had a verbal altercation with another client and this was done to reduce the potential for an altercation. LPA Smith was not able to interview C1 and C2 to gain additional clarifying information regarding the allegations. Based on confidential interviews and record review, the allegations that Staff are not treating minors equally and Staff are not providing minor with a comfortable environment may have occurred, however is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. A copy of this report and Appeals Rights were provided and explained to Facility Administrator, Reyna Corona.

Investigation Findings:
13On June 15, 2022 at 12:20 p.m., Licensing Program Analyst (LPA) Sarah Smith met with CFLC- Hemet Ranch Short Term Residential Therapeutic Program Facility Administrator, Reyna Corona to deliver the findings of the complaint investigation for the above allegations involving Clients (C1 and C2) in care. LPA Gonzalez conducted a health and safety inspection of the facility on 09/27/2021 at 11:57 a.m. and no immediate deficiencies were observed. During the course of investigating the allegations, LPA Smith conducted confidential interviews with Clients (C3, C4, C5, and C6), Staff (S1, S2, S3, S4, S5, and S6), and County Social Worker. LPA Smith attempted to interview C1 and C2 but they did not respond so no additional information could be obtained from them. On September 23, 2021, a complaint was received that Staff are not treating minors equally and Staff are not providing minor with a comfortable environment. Specifically, it was reported that C1 is often blamed for things that C2 does and when they are disciplined the punishment is not fair. It was also reported that UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Sarah Smith 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: CFLC-HEMET RANCHFACILITY NUMBER: VISIT DATE: 06/15/2022

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

met_with: Reyna Corona , Facility Administrator


summary: Complaint Investigation - Substantiated

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Narrative:
(Continued) Regarding the allegation that staff call clients inappropriate names, confidential interviews noted S1 was involved in a conversation between client C1 and C2 about why it is inappropriate to use the "N" word. Additional confidential interviews noted S1 said 'Nigger" several times while C1 and C2 requested S1 to stop. Review of documentation and confidential interviews noted S1 has also referred to the clients as "Bitches". A confidential interview confirmed using N word and B word, however it was not intended to be threatening. Based on confidential interviews, observations, and file reviews, the preponderance of evidence standard has been met, therefore, the allegation that S1 calling C1 inappropriate names is substantiated. The facility is being cited for violation of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards Section PERSONAL RIGHTS(c)(10). See LIC D. Exit interview was conducted. A copy of this report, LIC 811, and appeal rights were explained and provided to Case Manager, Reyna Corona.

Investigation Findings:
13On March 30, 2023, Licensing Program Analyst (LPA) Val Wilson met with Administrator Reyna Corona to issue the findings for the above stated allegation. Please see the Confidential Names List, LIC 811, dated March 30, 2023. On April 11, 2022, a safety inspection was conducted at CLFC Hemet Ranch Short-Term Residential Therapeutic Program (STRTP) and there were no noted concerns. LPA reviewed facility files and five client files [Client 1 (C1), Client 2 (C2), Client 3 (C3), Client 4 (C4), and Client 5 (C5)] and one staff file [Staff 1 (S1)]. LPA also obtained and reviewed copies of the LIC Register of Facility Clients, LIC Personnel Report, CFLC Policy and Procedure, staff evaluation, staff training, staff verbal warnings, Children and Family Team Minutes (CFTM), Needs and Services plans, and a county report. During the investigation, interviews were conducted with Administrator (ADM), Director (DIR), C1, C2, C3, C4, C5 and S1. On April 1, 2022, the Department received a complaint that alleged Personal Rights- Staff calling clients inappropriate names. Specifically, it was reported staff called a client the "N" word on several occasions with other clients present, the ADM discussed this with the staff, and staff called a client a "reverse racist". (Continued) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Valerie 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 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: CFLC-HEMET RANCHFACILITY NUMBER: 330908390

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
(Continued) of assigned chores, and the facility van and house are not kept clean. Regarding the allegation Client was not provided transportation from school, confidential interviews noted staff arrived late to the "school pick-up" on a minimum day. Staff began driving back to the house and picked up the Client close to the home. Additional interviews noted, S2 was not aware of the minimum day and this was the first time this has occurred at the facility. Other information states the allegation occurred. Regarding the cleanliness of the home and van, confidential interviews noted that staff refuse to clean the house if a client does not complete their chores. Additional interviews and observation revealed the ADM established expectations with the staff and the cleanliness of the home and van have not been a concern for a few months. Other information states the allegation occurred. Based on confidential interviews and information obtained, the allegation that C5 was not provided transportation by S2 from school in addition to a lack of cleanliness of the home and van may have occurred, however they are 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 Reyna Corona.

Investigation Findings:
13On March 30, 2023, Licensing Program Analyst (LPA) Val Wilson met with Administrator Reyna Corona to issue the findings for the above stated allegation. Please see the Confidential Names List, LIC 811, dated March 30, 2023. On April 11, 2022, a safety inspection was conducted at CLFC Hemet Ranch Short-Term Residential Therapeutic Program (STRTP) and there were no noted concerns. LPA reviewed facility files, and two client files [Client 1 (C1) and Client 5 (C5)]. LPA also obtained and reviewed copies of the LIC Register of Facility Clients, LIC Personnel Report, Needs and Services plans, a county report, and a special incident report dated 3/23/22. During the investigation, interviews were conducted with Administrator (ADM), Staff 2 (S2), C1, C2, C3, C4,and C5. On April 1, 2022, the Department received a complaint that alleged a client was not provided transportation from school. Specifically, a client walked home from school because staff didn't pick the client up. The staff told the client they should have waited at school and called staff to come get them. Additional reporting noted that instead of staff cleaning, staff wait until other clients do the cleaning (Continued) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Valerie 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 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: CFLC-HEMET RANCHFACILITY NUMBER: VISIT DATE: 03/30/2023


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
(Continued) a choke hold. Specifically, it was reported C1 walked behind S1, C1 accidentally tapped S1's back, and S1 put C1 in a choke hold. Regarding the allegation that S1 placed C1 in a choke hold, confidential interviews noted when S1 felt C1 touch their shoulder, S1 maneuvered their arm around C1's head into a hold. Additional confidential interviews noted a CFLC grievance form was filed, investigated, and found S1 used an unapproved intervention. Based on confidential interviews, observations, and file reviews, the preponderance of evidence standard has been met, therefore, the allegation that S1 placed C1 in a choke hold is substantiated. The facility is being cited for violation of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards Section Personal Rights(c)(11). See LIC D. Exit interview was conducted. A copy of this report, 9099D, LIC 811, and appeal rights were explained and provided to Administrator, Reyna Corona.

Investigation Findings:
13On July 21, 2023, Licensing Program Analyst (LPA) Val Wilson met with Administrator Reyna Corona to issue the findings for the above stated allegation. Please see the Confidential Names List, LIC 811, dated July 21, 2023. On June 28, 2022, a safety inspection was conducted at CLFC Hemet Ranch, Short-Term Residential Therapeutic Program (STRTP), and there were no noted concerns. LPA reviewed facility files and one client file [Client 1 (C1)] and one staff file [Staff 1 (S1)]. LPA also obtained and reviewed copies of the LIC Register of Facility Clients, LIC Personnel Report, CFLC Policy and Procedure, staff discipline, staff training, staff guidelines, emergency intervention plan, Needs and Services plan, grievance form, county report, and a Special Incident Report (SIR). During the investigation, interviews were conducted with client 1 (C1), client 2 (C2), client 3 (C3), administrator (ADM), and direct care staff 2 (S2). S1 was unable to be interviewed due to whereabouts unknown at this time. On July 22, 2022, the Department received a complaint that alleged staff placed minor in (Continued) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Valerie 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 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: CFLC-HEMET RANCHFACILITY NUMBER: VISIT DATE: 07/21/2023


raw_content:
Narrative:
(Continued) confidential interviews noted staff are present and provide supervision according to the program statement or enhanced when it is needed or required in the needs and service plan. Additional review of documents and confidential interviews note removing privacy during telephone/social media uses is against CFLC policy. Other information states the allegation occurred. Based on confidential interviews, observations, and file reviews, the allegation staff are not providing adequate supervision to C1 and C2, may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegations is unsubstantiated at this time. Exit interview was conducted. A copy of this report, 9099D, LIC 811, and appeal rights were explained and provided to Administrator, Reyna Corona.

Investigation Findings:
13On July 21, 2023, Licensing Program Analyst (LPA) Val Wilson met with Administrator Reyna Corona to issue the findings for the above stated allegation. Please see the Confidential Names List, LIC 811, dated July 21, 2023. On June 28, 2022, a safety inspection was conducted at CLFC Hemet Ranch, Short-Term Residential Therapeutic Program (STRTP), and there were no noted concerns. LPA reviewed facility files and one client file [Client 1 (C1)]. LPA also obtained and reviewed copies of the LIC Register of Facility Clients, LIC Personnel Report, CFLC Policy and Procedure, Needs and Services plan, county report, and a Special Incident Report (SIR). During the investigation, interviews were conducted with client 1 (C1), client 2 (C2), administrator (ADM), and direct care staff 1 (S1). On July 22, 2022, the Department received a complaint that alleged staff are not providing adequate supervision to minors. Specifically, it was reported C1 is being shown male content on social media by their biological father for C1's dating consideration and it is uncertain the age of the males. Additionally, the pictures made C2 uncomfortable. Regarding the allegation that staff are not providing adequate supervision to C1 and C2, (Continued) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Valerie 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 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: CFLC-HEMET RANCHFACILITY NUMBER: VISIT DATE: 07/21/2023


raw_content:
Narrative:
.*****Continued***** and smoked from a vape pen in S1's purse that possibly contained nicotine and marijuana, and S1's daughter connects with facility youth through social media to deal marijuana. Regarding the allegation that Y1 has access to S1's vape pen, confidential interviews deny S1 had a vape pen at the facility or in facility vehicles. Confidential interviews deny Y1's access to S1's personal belongings at the facility or in a facility vehicle. Confidential interviews deny Y1 was in contact with S1 or S1's daughter through social media to gain access to a vape pen that contains nicotine and or marijuana. Confidential interviews deny Y1 smoked a vape pen that belonged to S1 or Y1 smoked a vape pen in front of S1. Other information states the allegation occurred. Based on confidential interviews, the allegation that Y1 has access to S1's vape pen may or may not have occurred; However, they are not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, a copy of this report, and LIC 811 was provided to the Assistant Administrator

Investigation Findings:
13On March 6, 2024, at 2: PM, Licensing Program Analyst (LPA), Val Wilson, met with Assistant Administrator, Anel (Garcia) Panduro, at California Family Life Center (CFLC) Hemet Ranch, Short Term Residential Therapeutic Program (STRTP), to issue the findings for the above stated allegation involving the STRTP and youth listed on the confidential Names List, LIC 811, dated March 6, 2024. On March 13, 2023, at 3: PM, LPA Wilson arrived at the STRTP and a safety inspection was completed without any health and safety concerns observed. LPA Wilson reviewed client files, facility documents, and obtained copies of the client roster, LIC 500, needs and services plans, county reports, and Special Incident Reports (SIRs). During the investigation, interviews were conducted with the administrator (ADM), Program Director (PD), Behavioral Health Specialist (BHS), staff 1 (S1), staff 2 (S2), staff 3 (S3), facility manager (FM), youth 1 (Y1), youth 2 (Y2), youth 3 (Y3), youth 4 (Y4), youth 5 (Y5), youth 6 (Y6), youth 7 (Y7), and youth 8 (Y8). On March 6, 2023, the Department received a complaint that alleged a minor has access to staff's vape pen. Specifically, it was alleged that S1 leaves their purse accessible to youth, Y1 had access to *Continued* UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Valerie 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 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 Riverside, CA Facility Name: Cflc-hemet Ranchfacility Number: Visit Date: 03/06/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32.*****Continued***** and smoked from a vape pen in S1's purse that possibly contained nicotine and marijuana, and S1's daughter connects with facility youth through social media to deal marijuana. Regarding the allegation that Y1 has access to S1's vape pen, confidential interviews deny S1 had a vape pen at the facility or in facility vehicles. Confidential interviews deny Y1's access to S1's personal belongings at the facility or in a facility vehicle. Confidential interviews deny Y1 was in contact with S1 or S1's daughter through social media to gain access to a vape pen that contains nicotine and or marijuana. Confidential interviews deny Y1 smoked a vape pen that belonged to S1 or Y1 smoked a vape pen in front of S1. Other information states the allegation occurred. Based on confidential interviews, the allegation that Y1 has access to S1's vape pen may or may not have occurred; However, they are not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, a copy of this report, and LIC 811 was provided to the Assistant Administrator SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Valerie Wilson LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of 2

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

met_with: Anel (Garcia) Panduro


facility_name: CFLC-SUNSET HOUSE

raw_content:
Narrative:
On April 25, 2023, Community Care Licensing (CCL) received a complaint alleging that facility staff did not adequately supervise a minor while in care. It was reported to CCL that an adult male snuck into the facility with the help of client #1 (C1) resulting in a sexual interaction while in care and C1 obtaining drug paraphernalia from the adult male. During investigation, Investigator Vasquez found no corroboration for the above allegation. Investigator, Vasquez received inconsistent information that facility staff did not adequately supervise C1 while in care. Confidential interviews revealed that an unknown adult male did access the facility with C1's and C2's help resulting in a sexual interaction between C1 and the adult male and C1 obtaining a marijuana vape pen while in care. Some confidential interviews stated that there were no signs that indicated that something unusual was occurring at the facility and added that staff supervision was being provided to clients in care through room checks every 15 minutes on the day of the incident. Confidential interviews further stated that staff became aware of the incident after C1 revealed the information to a staff member. There were no other known witnesses to the allegation. Investigator, Vasquez received inconsistent information about whether neglect or lack of supervision by facility staff resulted in the adult male accessing the facility, having sexual intercourse with C1, and providing C1 with a marijuana vape pen while in care. Based on confidential interviews, the allegation that staff did not adequately supervise C1 while in care, may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Assistant Administrator/Client Services, Patricia' Parker

Investigation Findings:
13On December 29, 2023, at 9: AM, Licensing Program Analyst (LPA), Cynthia Urena met with CFLC-Sunset House Short Term Residential Therapeutic Program (STRTP) Assistant Administrator/Client Services, Patricia' Parker to deliver the investigative finding for the above stated allegation. On May 3, 2023, at 9: AM, LPA Daniel Mena initiated the investigation at the STRTP and collected pertinent documents from the STRTP program staff and client files. A health and safety inspection was conducted, and no immediate deficiencies were observed. LPA Mena informed the STRTP that Investigator, Wilfredo Vasquez would be leading the investigation. Investigator, Vasquez conducted interviews with a Riverside Sherriff's Department Investigator, four clients (C1, C2, C3, C4), five staff members (S1, S2, S3, S4, S5) and a witness. (**Continued on LIC C**) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Cynthia Urena 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 PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: CFLC-SUNSET HOUSEFACILITY NUMBER: VISIT DATE: 12/29/2023

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


raw_content:
Narrative:
Regarding the allegations that staff did not provide adequate supervision resulting in minor being sexually assaulted while in care, and that due to lack of care and supervision minor had access to a vape pen. It was revealed that an adult male known to C1 and C2 accessed the facility through a bedroom window and was assisted by C1 and C2 which resulted in C1 having sexual intercourse with the adult male without staff knowledge. Confidential interviews further stated the adult male also provided C1 with a "marijuana vape pen" that resulted in C1 and C2 engaging in substance use on the day of the incident. Confidential interviews further stated that S1 was on duty during the time that the incident occurred and was conducting room checks every 15-30 minutes but did not observe anything that indicated that something unusual was occurring at the facility. Confidential interviews also stated that the facility staff became aware of the incident after C1 revealed the information to a facility staff member and that the information was reported in a special incident report. There were no other known witnesses or corroborating evidence to support the above allegations. Based on confidential interviews, the allegation that staff did not provide adequate supervision resulting in C1 being sexually assaulted while in care, and that due to lack of care and supervision C1 had access to a vape pen, may have happened or is valid but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Direct Care Worker, Miriam Maturino.

Investigation Findings:
13On January 5, 2024, at 10: AM, Licensing Program Analyst (LPA), Cynthia Urena met with CFLC-Sunset House Short Term Residential Therapeutic Program (STRTP) Direct Care Worker, Miriam Maturino to deliver the investigative finding for the above stated allegations. On September 26, 2023, at 9: AM, LPA Cynthia Urena initiated the investigation at the STRTP and collected pertinent documents from the STRTP program staff and client files. A health and safety inspection was conducted, and no immediate deficiencies were observed. Regarding the above allegations, interviews were completed with four staff members (S1, S2, S3, S4), four clients (C1, C2, C3, C4), and a Riverside County Sheriff's Investigator. On September 21, 2023, Community Care Licensing (CCL) received a complaint alleging that staff did not provide adequate supervision resulting in minor being sexually assaulted while in care, and that due to lack of care and supervision minor had access to a vape pen. (**Continued on LIC C**) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Cynthia Urena 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 PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: CFLC-SUNSET HOUSEFACILITY NUMBER: VISIT DATE: 01/05/2024

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

met_with: Direct Care Worker, Miriam Maturino