raw_content:
Narrative:
Statements and evidence obtained indicated that staff have received training's for trauma informed care, preventive assaultive behaviors, emergency interventions, personal rights, prudent parenting, interpersonal relationships, and communication skills. There were no witnesses or documentary evidence to corroborate allegations. Due to a lack of evidence obtained during the investigation, LPA determined that the allegations are Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. There were no deficiencies at this time. An exit interview was conducted and copy of this report was left at the facility with the Assistant Vice President- Head of Service Timothy Lin

Investigation Findings:
13On March 22, 2024 at 10:15AM, Licensing Program Analyst (LPA), Rosslyn Gray made an unannounced visit to HATHAWAY-SYCAMORES CHILD AND FAMILY SERVICES to conclude the investigation. Prior to entering the facility LPA Gray conducted a health and safety risk assessment. During the investigation, LPA Gray interviewed all available parties and gathered pertinent information in reference to the allegations. During investigation, LPA conducted interviews and reviewed Special Incident Reports. Facility staff denied the allegations. Confidential statements indicated that children in care are treated with dignity and respect and not spoken to inappropriately. There were no statements to indicate that children in care were referred to using inappropriate names or that profanity was used towards them. There were no statements to indicate that staff intentionally provoked children in care so that they may receive restrictions. Statements indicated that children in care are treated with dignity and respect. There were no statements indicating that staff were observed to be disrespectful to children in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Rosslyn Y. Gray LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: HATHAWAY-SYCAMORES CHILD AND FAMILY SERVICESFACILITY NUMBER: VISIT DATE: 03/22/2024

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


state: CA

facility_name: HATHAWAY-SYCAMORES CHILD AND FAMILY SERVICES

summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13Licensing Program Analyst Connie Jones-Steward investigated the above allegations. LPA interviewed the administrator, the transport driver, C1 and C2. C3 could not be reached for interview. LPA also reviewed the Special Incident Report associated to the event. During the course of the investigation, LPA could not gather conclusive information as to whether or not staff properly implemented the facility run-away plan or picked up C1 from the hospital in a timely manner. LPA Jones-Steward was not able to obtain a missing person's report form Altadena Sheriffs due to thier practice of not issuing a report number at the time that an AWOL is reported, but only after they have visited the facility or the child has been missing for 25 hours.. Therefore these allegations are resolved as unsubtantiated. Unsubstantiated means that although an allegation may have happened or is valid, there is not a preponderance of evidence that it did occur. This report was amended on 10/30/2024 to add additional information. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

report_type: Complaint Investigation

met_with: Jodi Maberry

complaint_status: unsubstantiated


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Investigation Findings:
13On May 7, 2025 and 2:25PM Licensing Program Analyst (LPA) Justine Armstrong conducted an unannounced visit to HATHAWAY-SYCAMORES CHILD AND FAMILY SERVICES to conclude the investigation of the above allegations and deliver the findings. LPA met with Tasian Taylor the Facility Administrator who granted access to the facility and together, they discussed the investigation details. During the investigation process, all relevant parties have been accounted for. It was reported that Staff physically assaulted minor while in care. After conducting confidential interviews and reviewing record documents, there was insufficient evidence or testimony to substantiate the allegations. Although the allegation may have happened or is valid and some evidence was concerning, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has decided that the allegation Staff physically assaulted minor while in care is Unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There were no deficiencies cited. An exit interview was completed, and a copy of this report was provided to the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Enrique M Hernandez LICENSING EVALUATOR NAME: Justine Armstrong LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Tasian Taylor


raw_content:
Investigation Findings:
13On May 7, 2025 at 2:25PM Licensing Program Analyst (LPA) Justine Armstrong conducted an unannounced visit to HATHAWAY-SYCAMORES CHILD AND FAMILY SERVICES to conclude the investigation of the above allegations and deliver the findings. LPA met with Tasian Taylor who granted access to the facility and together, they discussed the investigation details. During the investigation process, all relevant parties have been accounted for. It was reported that (1) Staff tased youth in care. (2) Staff threaten youth in care. After conducting confidential interviews and reviewing record documents, there was insufficient evidence or testimony to substantiate the allegations. Although the allegation may have happened or is valid and there was some concerning evidence, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has decided that the allegation that (1) Staff tased youth in care (2) Staff threaten youth in care while in care is Unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There were no deficiencies cited. An exit interview was completed, and a copy of this report was provided to the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Enrique M Hernandez LICENSING EVALUATOR NAME: Justine Armstrong LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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


summary: Facility Evaluation

raw_content:
Narrative:
On September 21, 2021, at 8:00am Licensing Program Analysts (LPAs), Emelyn Sanchez P. and Olivia Rosas arrived at the above facility unannounced for the purpose of conducting a SB Psychotropic Medication Case Management- Medication Inspection Visit. LPAs Sanchez P. and Rosas met with Daisy Delgado, Director of Residential Treatment Programs. LPAs Sanchez P. and Rosas reviewed six (6) client files and three (3) staff files. LPAs Sanchez P. and Rosas conducted three (3) client interviews and three (3) staff interviews. Currently there are twenty-one (21) clients residing in the above facility. This is a facility located in a residential area and equipped with a kitchen/dinning room, three cottages that have a living room, laundry space, small kitchen, bathrooms and bedrooms. There is also an Art Room, Recreational Hall, Medication Office, an outdoor BBQ patio, and basketball court. Outdoor space is free of obstructions. LPAs Sanchez P. and Rosas observed the facility to be clean, safe, sanitary and in good repair. LPAs Sanchez P. and Rosas observed adequate staffing in the facility to provide care and supervision to children in care. LPAs Sanchez P. and Rosas also observed medication to be centrally stored, triple locked and inaccessible to clients and unauthorized staff members. There were no deficiencies cited at this time. Exit interview was conducted, and a copy of this report was left at the facility.

report_type: Facility Evaluation

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On 10/14/ Licensing Program Analyst (LPA) Bernice Karnsrithong and Rosslyn Gray arrived at the facility at 9:30am unannounced for the purpose of conducting an Annual/Required Inspection. LPAs met with Administrator for the Short Term Residential Therapeutic Program at Hathaway Sycamores Child and Family Services. The facility is licensed to care for 43 children ages 11 to 17 and non-minor dependents, ambulatory only. At that time of inspection there were 25 clients present at the facility. The Facility is located in a residential area and was set as follows: Administrative Office and Circle M: Administrative office consist of receptionist area, two bathrooms, staff kitchen and 10 offices. LPAs observed cameras located in hallway and outside rear of building. Circle M consist of therapy room, two bathrooms, 16 offices, staff kitchen and 10 cubicles. Cameras are monitored through the leadership staff and IT Department. There is a camera waiver on file. Postings are available in the administrative office area. Currently, therapy sessions are being conducted outside due to COVID-19. Rowland Cottage (A-Hall and B-Hall): A-Hall consist of 9 bedrooms. 8 bedrooms are equipped with one twin size bed. One bedroom is equipped with two twin size beds. All bedrooms have adequate drawers, closet space, clean linen, lighting, and a desk and chair. B-Hall consist of 7 bedrooms. 6 bedrooms are equipped with one twin size bed. Currently B-Hall has 10 beds. All bedrooms have adequate drawers, closet space, clean linen, lighting, and a desk and chair. Individual beds were observed to be in good repair with clean linens. Each hall is equipped with one staff bathroom and one client bathroom which consist of two showers, two toilet stalls and two sinks. Each hall consists of a kitchen which contains a refrigerator, stove, microwave, toaster, dishwasher, and toaster oven. Knives, cleaning supplies and chemicals are inaccessible to children and located at the staff office. A-Hall dining area consist of ten chairs and two tables. (page 1 of 3) B-Hall dining area consist of one table and two chairs. There is a staff office, storage room and laundry area on each side of the hall. Each side of the cottage have a common room that is equipped with a television and couch seating for clients in care. There are 3 staff on each side of the hall, supervising children in the common area/kitchen. There are 3 fire extinguishers located in each hall. Smoke alarms and carbon monoxide detectors are in working order. Fire extinguishers have been serviced and are fully charged. First Aid kits are located on the staff office. Rules, Personal Rights and menu are posted in cottage. LPAs observed cameras located in living room and hallway of A-Hall and dayroom of B-Hall. Hunter Cottage (A-Hall and B Hall): A-Hall is currently not being used. B-Hall consist of 8 bedrooms. 7 bedrooms are equipped with one twin size bed. 7 rooms have one twin size bed and 1 room has two twin size beds. All bedrooms have adequate drawers, closet space, clean linen, lighting and a desk and chair. Each hall is equipped with one staff bathroom and one client bathroom which consist of two showers, two toilet stalls and two sinks. Individual beds were observed to be in good repair with clean linens. Each hall consists of a kitchen which contains a refrigerator, stove, microwave, toaster, dishwasher, and toaster oven. Knives, cleaning supplies and chemicals are inaccessible to children and located at the staff office. A-Hall dining area consist of 9 chairs and two tables. B-Hall dining area consist of two tables and nine chairs. There is a staff office, storage room, incentive room, shoe closet and laundry area. There is a sensory room that has video game console, comfortable seating and chalkboard walls that can be used by clients. Smoke alarms and carbon monoxide detectors are in working order. Fire extinguishers have been serviced and are fully charged. First Aid kits are located on the staff office. Rules, Personal Rights and menu are posted in cottage. Baldwin Cottage: This cottage is currently closed and non-operational. All prescribed medications are locked and centrally stored in the Nurse's Station with the exception of contraceptives. Licensee has provisions for contraceptives to be held in individually locked containers by clients. Facility has cameras in common areas of the facility. No firearms or weapons are allowed in the facility. Outdoor spaces are utilized for therapy and extracurricular activities. The campus has a recreation room that has sporting and exercise equipment. The campus has a basketball court, outdoor exercise equipment, baseball batting range, swings, and picnic tables spread across the lawn. (page 2 of 3) Licensee has a plan to ensure core services are provided and all staff are aware of it and are supportive and trained in their respective roles. Licensee is utilizing trauma informed care practices to ensure effective outcomes that promote permanency and client well-being. Licensee has a plan to ensure individual treatment needs are assessed at least every 30 days and recommendations are implemented. Licensee has a plan to assess, coordinate delivery and evaluate specialty mental health services for clients. Licensee has a maintenance office and a centralized kitchen. Meals are being prepared and cooked in the kitchen. Kitchen staff currently deliver the meals to the cottages in food warmers for COVID-19 prevention. Licensee has a designated mental health head of service staff who communicates and collaborates with county inter-agency placement committees to ensure specialty mental services are delivered. Clients are advised of their personal rights and house rules. Gender identity, expression and orientation are respected and kept confidential. Clients receive services, activities and support and are included in child and family teams regarding decisions about their plans. Clients can file a complaint or elevate concerns without retaliation. Licensee provides resident councils and forms for clients to raise issues. Clients are provided extracurricular activities such as hiking, biking, boxing, go on outings (Theme Parks, Movies, Beaches). The facility has 9 vehicles and are all operating in good condition. Administrator is present at the facility a minimum of 20 hours a week, as verified by staff schedule and interviews. Administrator job title is Assistant Director and oversees the Short Term Residential Therapeutic Program. Appropriate staff/client ratios were verified and meet regulations. Personnel files were reviewed to ensure staff meet regulatory requirements. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. All file documentation is complete, signed and current for each staff. All emergency intervention training is current. Staff is aware of the mission and vision, and values for their program's continuous quality improvement. LPAs will return to the facility at a later date to complete the remaining staff interviews, client interviews and client records. LPAs concluded the inspection and a copy of this report will be emailed to the Administrator on 10/15/2021. (page 3 of 3)

visit_type: Annual

met_with: Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On Tuesday, October 19, 2021 at 12:45pm Licensing Program Analyst (LPA) Bernice Karnsrithong met with Administrator, Tasian Taylor for the purpose of Case Management-Annual Continuation Inspection. LPA reviewed (10) client records, conducted (2) two client interviews and (4) four staff interviews. During this inspection, LPA had observed the following on the client's records: 1. Placement Worker and Placement Agency Information 2. Needs and Services Plan 3. Consent For Services 4. Acknowledgement Forms for Policies 5. Medication Log (Over the Counter and Psychotropic Medications) 6. Register/Record of Client's Allowances *All information and records pertaining to clients are kept confidential at all times. Client records are uploaded into a digital portal and can only be accessed by authorized facility users. However, records are provided to LPA during inspection. During the interviews, clients stated that they are involved during the Needs and Service Plan update meetings. Clients stated that cottage staff regularly checks in on their well-being during their stay. Clients stated that they received a weekly allowance that is provided to them by staff on Fridays. Clients stated that there is ample supply of food stored in their cottages and they have access to it. Clients stated that the facility provides them with a monthly clothing allowance and that staff takes them to the store to purchase clothing and shoe items they needed. There were no deficiencies cited at this time. Copy of this report will be provided to the administrator on October 20, 2021.


summary: Facility Evaluation

raw_content:
Narrative:
On 03/29/2022 at 9am, Licensing Program Analyst (LPA) Bernice Karnsrithong made an unannounced visit for the purpose of conducting a Case Management-Incident regarding Special Incident Report (SIR) #804435. Health and safety assessment were conducted upon arrival and COVID-19 protocols were observed. LPA Karnsrithong met with Jodi Maberry, Program Supervisor who granted access to the facility. On 03/24/2022, Community Care Licensing (CCL) received a SIR dated on 03/23/2022 regarding client's verbal and physical aggression towards staff involving physical restraint. During the visit, LPA Karnsrithong had conducted confidential interviews and reviewed documentary evidences pertaining to the incident. During the visit, not all parties were available for interview. At this time there are no sufficient evidence to render a decision. There are no deficiencies cited at this time and an exit interview was conducted with Jodi Maberry, Program Supervisor

met_with: Jodi Maberry, Program Supervisor


summary: Facility Evaluation

raw_content:
Narrative:
On 03/29/2022 at 9am, Licensing Program Analyst (LPA) Bernice Karnsrithong made an unannounced visit for the purpose of conducting a Case Management-Incident regarding a self-reported incident on 02/14/2022. Health and safety assessment were conducted upon arrival and COVID-19 protocols were observed. LPA Karnsrithong met with Daisy Delgado, Program Director who granted access to the facility. During the visit, LPA Karnsrithong had conducted confidential interviews and reviewed documentary evidences. During the visit, not all parties were available for interview. At this time, there are no sufficient information to render a decision. There are no deficiencies cited at this time and an exit interview was conducted with Daisy Delgado, Program Supervisor

met_with: Daisy Delgado, Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On 03/29/2022 at 9am, Licensing Program Analyst (LPA) Bernice Karnsrithong made an unannounced visit for the purpose of conducting a Case Management. LPA Karnsrithong met with Daisy Delgado, Program Director who granted access to the facility. Health and safety assessment were conducted at upon arrival and COVID-19 protocols were observed. During the visit, LPA Karnsrithong conducted a case management regarding the facility's Short Term Residential Therapeutic Program (STRTP) ONE. This facility only has one client in the program. The program is being housed at the Baldwin Cottage. It has one (1) bedroom that is equipped with a twin sized bed, a sturdy mattress, a desk and closet space with locker. It also has a kitchen that has a four-burner stove, a refrigerator, a microwave, and a sink. Client was observed to be making a sandwich at the time of the visit. There is ample supply of perishable and non-perishable food items at the time of the visit. The client is able to prepare his own meals and have access to utensils, pots, pans, and food supplies when needed. Hot meals that are prepared in the main kitchen are also being delivered to the living unit. There is an extra desk outside the bedroom near the kitchen area that has the telephone. There is a dining table that has four (4) chairs that the client can use during meals or for studying. There is an extra room in the living unit that is currently used as a storage for extra supplies. This room is kept locked and inaccessible for the client. A client bathroom is also located inside the living unit. It has a shower, sink, and toilet that are in good repair. There is a linen cabinet storage outside of the client bathroom. There is a living room/common room in the unit that has three (3) couches, a coffee table, television, and air purifier. Outside the living unit is a staff room that is equipped with a desk, computer, chair, a bed, and closet space with a locker. This is attached to the other side of the Baldwin Cottage and currently has no clients staying onsite. There is a staff bathroom here as well that is equipped with a shower, toilet, sink and cabinet. (Page 1 of 2) The facility has been observed in good repair. The temperature of the rooms are all in a safe range. During the time of visit, two (2) staff were observed to be supervising the client. LPA Karnsrithong has observed the client being on crisis and was being supported by three (3) staff. Client refused to be interviewed at that time of visit. Staff were observed to provide crisis communication to the client at the time of the visit. At this time, there are no sufficient information to render a decision. There are no deficiencies cited at this time and an exit interview was conducted with Daisy Delgado, Program Director. (Page 2 of 2)


summary: Facility Evaluation

raw_content:
Narrative:
On 04/08/2022 at 1pm, Licensing Program Analyst (LPA) Bernice Karnsrithong made an unannounced visit for the purpose of conducting a Case Management-Incident regarding Special Incident Report (SIR) #804435. Health and safety assessment were conducted upon arrival and COVID-19 protocols were observed. LPA Karnsrithong met with Jose Gallegos, Program Manager who granted access to the facility. During the visit LPA Karnsrithong interviewed one (1) client and one (1) staff. Not all parties were available during the visit. At this time, there is no sufficient information to render a decision. There are no deficiencies cited at this time and an exit interview was conducted with Jose Gallegos, Program Manager. A copy of this report will be provided to the facility.

met_with: Jose Gallegos, Program Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 04/08/2022 at 12:30pm, Licensing Program Analyst (LPA) Bernice Karnsrithong made an unannounced visit for the purpose of conducting a Case Management-Incident regarding a self-reported incident on 02/14/2022. Health and safety assessment were conducted upon arrival and COVID-19 protocols were observed. LPA Karnsrithong met with Jose Gallegos, Program Manager who granted access to the facility. During the visit LPA Karnsrithong interviewed two (2) clients regarding the special incident that occurred on 02/14/2022. Due to insufficient information a decision cannot be rendered at this time. There are no deficiencies cited at this time and an exit interview was conducted with Jose Gallegos, Program Manager. A copy of this report will be provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 05/03/2022 at 10am, Licensing Program Analyst (LPA) Bernice Karnsrithong arrived at the facility for the purpose of conducting a Case Management-Incident regarding a self-reported incident on 02/14/2022. Health and safety risk assessment were conducted upon arrival and COVID-19 protocols were observed. LPA Karnsrithong met with Daisy Delgado, Administrator who granted access to the facility. During the case management, LPA Karnsrithong has conducted confidential interviews and reviewed documentary evidences. Based on the confidential interviews and documentary evidences, the facility staff were able to comply with safety protocols and appropriate reporting procedures for the said incident. Facility staff reported the incident in a timely manner to appropriate agencies and law enforcement. There was no corroborating evidence to prove that a violation has occurred. The case management is deemed unsubstantiated and an exit interview was conducted with Daisy Delgado, Administrator. There are no deficiencies cited at this time. A copy of this report will be provided to the facility.

met_with: Daisy Delgado, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 05/03/2022 at 10am, Licensing Program Analyst (LPA) Bernice Karnsrithong arrived at the facility for the purpose of conducting a Case Management-Incident regarding Special Incident Report (SIR) #804435 that occurred on 03/23/2022. Health and safety risk assessment were conducted upon arrival and COVID-19 protocols were observed. LPA Karnsrithong met with Daisy Delgado, Administrator who granted access to the facility. During the case management, LPA Karnsrithong has conducted confidential interviews and reviewed documentary evidences. Based on the confidential interviews and documentary evidences, the facility staff were able to comply with appropriate emergency intervention practices to maintain the safety of staff and clients during a crisis. Statements were consistent that all safety measures and intervention provided to clients were appropriate and implemented for the well-being and safety of all parties involved. Confidential interviews did not produce corroborating evidence to support that staff are not complying with emergency intervention procedures at the time of the incident. This determines that this case management is deemed unsubstantiated meaning that there is not a preponderance of the evidence to prove that a violation has occurred. There were no deficiencies cited at this time. Exit interview conducted with administrator, Daisy Delgado. A report will be provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 06/17/2022 at 9:50am, Licensing Program Analyst (LPA) Bernice Karnsrithong arrived at the facility to conduct a case management-incident. Health and safety risk assessment were conducted upon arriving at the facility. LPA Karnsrithong met with Jodi Maberry, Program Supervisor who granted access and tour to the facility. On 05/10/2022 a Special Incident Report (SIR), SIR #81171 and SIR#811764 was submitted in regard to a client that was restraint twice that day due to assaultive behavior. SIR indicated that client was in a restraint at 3:05pm and 9:05pm on 05/10/2022. During the visit, LPA Karnsrithong conducted confidential interviews and reviewed documentary evidences. LPA Karnsrithong toured the client's living area. Not all parties were available for interview at this time and a decision cannot be rendered. There are no deficiencies cited at this time and a copy of this report will be provided.


summary: Facility Evaluation

raw_content:
Narrative:
On 06/21/2022 at 1:30pm, Licensing Program Analyst (LPA) Bernice Karnsrithong arrived at the facility to conduct a case management-incident. Health and safety risk assessment were conducted upon arriving at the facility. LPA Karnsrithong met with Daisy Delgado, Administrator who granted access and tour to the facility. On 05/10/2022 a Special Incident Report (SIR), SIR #81171 and SIR#811764 was submitted regarding a client that was restraint twice that day due to assaultive behavior. SIR indicated that client was in a restraint at 3:05pm and 9:05pm on 05/10/2022.During the visit, LPA Karnsrithong conducted three (3) confidential interviews. Not all parties were available at the time of the visit. A decision cannot be rendered. This case management-incident needs further investigation. Exit interview was conducted with Daisy Delgado, Administrator. There are no deficiencies cited at this time and a copy of this report will be provided.


summary: Facility Evaluation

raw_content:
Narrative:
On 07/19/2022 at 10am, Licensing Program Analyst (LPA) Bernice Karnsrithong arrived at the facility to deliver findings for the Case Management-Incident regarding SIR #81171 and SIR#811764. On 05/10/2022 a Special Incident Report (SIR), SIR #81171 and SIR#811764 was submitted in regard to a client that was restraint twice that day due to assaultive behavior. SIR indicated that client was in a restraint at 3:05pm and 9:05pm on 05/10/2022. During the case management-incident, LPA Karnsrithong conducted confidential interviews and reviewed documentary evidences. Based on the incident reports, confidential interviews and documentary evidences; statements were consistent that appropriate emergency intervention procedures and protocols were implemented to support the needs and safety of the client and staff involved in the incidents on 05/10/2022. There was no corroborating evidence that supports that a violation has occurred. This case management-incident has been found to be unsubstantiated. There are no deficiencies cited at this time. Exit interview was conducted with Daisy Delgado, Director of Residential Programs. A copy of this report will be provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 11/15/2022, Licensing Program Analyst (LPA) C. White made an unannounced visit to the above facility for the purpose of conducting a Required Inspection. LPA met with Daisy Delgado, Director of Residential Programs. The facility is licensed to care for 43 children ages 11 to 17 and non-minor dependents, ambulatory only. At that time of inspection, the census was 28. The Facility is located in a residential area and is set up as follows: Administrative Office, Circle M building, 3 cottages (Rowland, Hunter, and Baldwin), a Dinning Hall, Nurses Office, Maintenance Room, Music Room, a Recreation room, and 2 family cottages. Administrative Office: contains a receptionist area, 10 staffing offices, a board room, 2 bathrooms, and a staff's kitchen. Circle M: contains a therapy room, 16 offices, multiple cubicles, 2 bathrooms, and a staff's kitchen. Rowland Cottage: The cottage is divided into two sides named Hall A and Hall B. Hall A: contains 8 bedrooms, 1 bedroom is equipped with two (2) twin size beds, the remaining 7 bedrooms are equipped with one (1) twin bed. All bedrooms have adequate drawers, closet space, and lighting. Hall B: contains 8 bedrooms, 2 bedroom are equipped with two (2) twin size beds, the remaining 6 bedrooms are equipped with one (1) twin bed. All bedrooms have adequate drawers, closet space, and lighting. All beds were observed to be in good repair. Both halls contain a dining area, a kitchen, two bathrooms, a staffing office, a common area, and a laundry room. The dining area contains a table and ample seating. The kitchens are equipped with a refrigerator/freezer, a gas burning stove, a microwave, and dishwasher. Bathrooms, one bathroom is for staff and one bathroom for clients. Client bathrooms contain two showers, two toilet stalls and two sinks. Report continued on LIC 809C Staffing office is equipped with a desk, chair, computer, and two storage cabinets observed to contain individual storage boxes for each client, additional linen supplies, and hygiene items. Sharp knives, soap/detergent, and disinfectants are also kept locked in the staffing office and made inaccessible to clients. The common area contains a mounted television and ample seating. Laundry room contains a washer and dryer. Hunter Cottage: The cottage is divided into two sides named Hall A and Hall B. (A-Hall and B Hall): Hall A: 7 rooms, 1 bedroom is equipped with two (2) twin size beds, the remaining 6 bedrooms are equipped with one (1) twin bed. All bedrooms have adequate drawers, closet space, and lighting. This Hall is closed and not currently in use. Hall B: contains 8 bedrooms, 1 bedroom is equipped with two (2) twin size beds, the remaining 7 bedrooms are equipped with one (1) twin size bed. All bedrooms have adequate drawers, closet space, and lighting. All beds were observed to be in good repair. Both halls contain a dining area, a kitchen, two bathrooms, a staffing office, a common area, and a laundry room. Additionally, Hall B contains an incentive room with a television for video games and a couch. The dining area contains a table and ample seating. The kitchens are equipped with a refrigerator/freezer, a gas burning stove, a microwave, and dishwasher. Bathrooms, one bathroom is for staff and one bathroom for clients. Client bathrooms contain two showers, two toilet stalls and two sinks. Staffing office is equipped with a desk, chair, computer, and two storage cabinets observed to contain individual storage boxes for each client, additional linen supplies, and hygiene items. Sharp knives, soap/detergent, and disinfectants are also kept locked in the staffing office and made inaccessible to clients. The common area contains a mounted television and ample seating. Laundry room contains a washer and dryer. Baldwin Cottage: Is non-operational. All prescribed medications, including medications requiring refrigeration are locked and centrally stored in the Nurse's Station. There are no weapons or bodies of water on the premises. The recreation room was observed to have exercise equipment and games. The outdoor area contains a basketball court, baseball batting area, swings, outdoor exercise equipment, a picnic area, and a garden. Report continued on LIC 809C. Smoke alarms and carbon monoxide detectors were tested and found to be in working order. There are multiple regulation fire extinguishers located throughout the facility and in each cottage. First Aid kits checked and found to be complete. Hot water was tested and found to be between 105-120 degrees (F). Overall LPA observed the facility to be clean, safe, sanitary and in good repair. Temperatures in client rooms and common areas were found to be between 68 - 85 degrees (F). Additional disinfectants/cleaning solutions are stored in the maintenance room and made inaccessible to clients. The facility operates within license conditions and limitations including capacity limitations. LPA discussed and advised the Licensee to ensure the following: Children are supported and encouraged to participate in extracurricular activities. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. Personal Rights, menus, and activities were posted in one each side of the cottages. Transportation: The facility has a total of 7 vehicles to transport clients. LPA inspected 3 out of 7 vehicles and found seat belts and horn in working order, travel first aid kits, and current registration and insurance. Vehicles are insured by Nonprofit Insurance Alliance of CA and expire 11/1/2023. LPA observed cameras in the common areas, and on the outside perimeter of the buildings. The cameras are monitored by the administrative staff and the IT Department. There is a camera waiver on file. LPA will return at a later date to review client and staff records, as well as conduct client and staff interviews. There are no deficiencies observed or cited at this during this inspection. An exit interview was conducted with the Director of Residential Programs, and of this report was left at the facility.

met_with: Director of Residential Programs - Daisy Delgado


summary: Facility Evaluation

raw_content:
Narrative:
On 12/29/2022, Licensing Program Analyst (LPA) Bernice Karnsrithong arrived at the facility at 9am for the purpose of reducing the facility's capacity to sixteen (16). Health and safety risk assessment was conducted upon arriving at the facility. LPA Karnsrithong met with Daisy Delgado, Director of Residential Programs who granted tour and access to the facility. This facility is licensed to provide care and supervision up to sixteen (16) children ages six (6) to seventeen (17) ambulatory only and to Non-Minor Dependents (NMD). The facility is composed of one (1) living area for clients, Rowland Cottage. This cottage has a total of sixteen (16) bedrooms. It is subdivided in two hallways (Rowland A and Rowland B). Each side of this cottage has its own staff office, laundry area, and staff bathroom. Each side has its own common area that has the living room and dining/kitchen area. The cottage has two (2) bathrooms that clients use. Each of these bathrooms have two (2) toilets and two (2) shower stalls. The current census of Rowland Cottage is sixteen (16). Currently Family Cottages and Baldwin Cottage is being used for isolation for COVID-19. Baldwin Cottage is also being used for storage. During the visit, one of the family cottages were being used as an isolation room for one (1) client that is COVID-19 positive. The isolation areas are labeled "Red Zone" when it is in use. The facility has updated its program statement to reflect the changes regarding the facility's designated isolation area and storage.


summary: Facility Evaluation

raw_content:
Narrative:
On August 9, 2023, Licensing Program Analyst (LPA) C. White made an unannounced visit to Hathaway-Sycamores for the purpose of conducting a Case Management for Special Incident Report #08-2023-34-CM-04. The incident occurred 08/06/2023 and the incident report was received by the Department on 08/07/2023. LPA met with Timothy Lin, Assistant Vice President of Residential Programs and discussed the incident. During this visit, confidential interviews were conducted. Additionally, LPA requested a copy of the following documents: Staff #2's and Staff #3's restraint training records, Client #1's intake paperwork, and Behavior Log documentation. Based on interviews and information gathered, this case management needs further investigation. Exit interview was conducted, and a copy of this report was left with the Assistant Vice President of Residential Programs.

met_with: Assistant Vice President of Residential Programs - Timothy Lin


summary: Facility Evaluation

raw_content:
Narrative:
On 11/21/2022, Licensing Program Analyst (LPA) C. White made an unannounced visit to the above facility for the purpose of conducting a Required Inspection. LPA met with Timothy Lin, Assistant Vice President. The facility is licensed to care for 16 children ages 11 to 17 and non-minor dependents, ambulatory only. At the time of today's inspection, the census was 14. The Facility is in a residential area and is set up as follows: Administrative Office, Circle M Building, Rowland Cottage, a Dining Hall, Nurses Office, Maintenance Room, Music Room, a Recreation room, and Family Cottages. Administrative Office: contains a receptionist area, 10 staffing offices, a board room, 2 bathrooms, and a staff's kitchen. Circle M Building: contains a therapy room, mental health staffing offices, multiple cubicles, 2 bathrooms, and a staff kitchen. Rowland Cottage Hall A: The hall contains a dining area, a kitchen, 8 bedrooms, two bathrooms, a staffing office, a common area, and a laundry room. Dining area: contains a table and ample seating. Kitchen: is equipped with a refrigerator/freezer, a 4-burner gas stove (operable at the time of inspection), a microwave, and dishwasher. Bedrooms: each bedroom is equipped with one (1) twin size bed. All bedrooms were observed to have beds in good repair, pillows, clean linen, adequate drawers, closet cabinets equipped with locked container, and lighting. Bathrooms: one bathroom is for staff and one bathroom for clients. Client bathrooms contain two showers, two toilet stalls and two sinks. Report continued on LIC 809C. Staffing Office: is equipped with a desk, chair, computer, and two storage cabinets observed to contain individual storage boxes for each client, additional linen supplies, and hygiene items. Sharp knives, soap/detergent, and disinfectants are also kept locked in the staffing office and made inaccessible to clients. Common area: contains a mounted television and ample seating. Laundry room: contains a washer and dryer. Rowland Cottage Hall B: The hall contains a dining area, a kitchen, 8 bedrooms, two bathrooms, a staffing office, a common area, and a laundry room. Dining area: contains a table and ample seating. Kitchen: is equipped with a refrigerator/freezer, a 5-burner gas stove (operable at the time of inspection), a microwave, and dishwasher. Bedrooms: each bedroom is equipped with one (1) twin size bed. All bedrooms were observed to have beds in good repair, pillows, clean linen, adequate drawers, closet cabinets equipped with locked container, and lighting. Bathrooms: one bathroom is for staff and one bathroom for clients. Client bathrooms contain two showers, two toilet stalls and two sinks. Staffing Office: is equipped with a desk, chair, computer, and two storage cabinets observed to contain individual storage boxes for each client, additional linen supplies, and hygiene items. Sharp knives, soap/detergent, and disinfectants are also kept locked in the staffing office and made inaccessible to clients. Common area: contains a mounted television and ample seating. Laundry room: contains a washer and dryer. All prescribed medications, including medications requiring refrigeration, are locked and centrally stored in the Nurse's Office. There are no weapons or bodies of water on the premises. The recreation room was observed to have exercise equipment and games. The outdoor area contains a basketball court, baseball batting area, swings (area is cushioned with woodchips), outdoor exercise equipment (securely anchored to the ground), a picnic area, and a garden. Transportation: The facility has a total of 5 vehicles to transport clients. LPA inspected 2 out of 5 vehicles and found seat belts and horns in working order, travel first aid kits, and current registration and insurance. Vehicles are insured by Nonprofit Insurance Alliance of CA and expire 11/1/2024. Report continued on LIC 809C Smoke alarms and carbon monoxide detectors were tested and found to be in working order. There are multiple regulation fire extinguishers located throughout the facility and in each cottage. First Aid kits checked and found to be complete. Hot water was tested and found to be between 105-120 degrees (F). Overall LPA observed the facility to be clean, safe, sanitary and in good repair. Temperatures in client rooms and common areas were found to be between 68 - 85 degrees (F). Additional disinfectants/cleaning solutions are stored in the maintenance room and made inaccessible to clients. The facility operates within license conditions and limitations including capacity limitations. LPA discussed and advised the Licensee to ensure the following: Children are supported and encouraged to participate in extracurricular activities. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. Personal Rights, menus, and activities were posted in one each side of the cottages. LPA observed cameras in the common areas, and on the outside perimeter of the buildings. The cameras are monitored by the administrative staff and the IT Department. There is a camera waiver on file. LPA will return at a later date to review client and staff records, as well as conduct client and staff interviews. There are no deficiencies observed or cited at this during this inspection. An exit interview was conducted with the Assistant Vice President, and of this report was left at the facility.

met_with: Assistant Vice President - Timothy Lin


summary: Facility Evaluation

raw_content:
Narrative:
On 11/22/ 2023 at 9: AM, Licensing Program Analyst (LPA) C. White, made an announced visit to Hathaway-Sycamores Child and Family Services, for the purpose of conducting a Case Management Annual Continuation Inspection. LPA met with Director of Residential Programs, Daisy Delgado. LPA was granted access to the facility and provided the requested information. LPA reviewed the following records during the inspection: Client Records: The program currently has a total of sixteen (16) clients. LPA reviewed five (5) client records and found each record to meet required regulations. Staff Records: The program currently has a total thirty (30) staff. LPA reviewed a total of six (6) staff records and confirmed files contained staff qualifications, current CPR/First Aid cards, health screening, and TB test results. LPA obtained the LIC 500 to verify Staff to Client ratio. LPA reviewed the Facility Profile and Personnel Report and confirmed that personnel have required criminal record clearance: DOJ, FBI and Child Abuse; which meet qualification. LPA conducted interviews with three (3) clients and a total of three (3) staff. This inspection included an overview of required Core Services and Supports and based upon inspection of facility records and interviews of staff and clients. Licensee is meeting all requirements. There were no deficiencies cited per California Code of Regulations and Interim Licensing Standards. Exit interview was conducted, Appeal Rights and a copy of this report was given to the Director of Residential Programs.


summary: Facility Evaluation

raw_content:
Narrative:
On March 4, 2024 at 9: AM, Licensing Program Analyst (LPA) C. White made an unannounced visit to Hathaway-Sycamores Child and Family Services, for the purpose of conducting a Case Management for Special Incident Report #1011234. The incident occurred 02/24/2024 and the incident report was received by the Department on 02/25/2024. LPA met with Chief Program Officer, Joe Ford and discussed the incident. During this visit, LPA conducted confidential interviews, and reviewed video footage. Additional interviews will be conducted on a later date. LPA requested copies of the following documents: LIC 500, Client Roster, Staff #1's training records and contact information. Additionally, LPA was informed that Staff #1 is out on leave. Based on interviews and information gathered, this case management needs further investigation. Exit interview was conducted, and a copy of this report was emailed to the Chief Program Officer.

met_with: Joe Ford - Chief Program Officer


summary: Facility Evaluation

raw_content:
Narrative:
On March 4, 2024 at 10: AM, Licensing Program Analyst (LPA) C. White made an unannounced visit to Hathaway-Sycamores Child and Family Services, for the purpose of conducting a Case Management for Special Incident Report #1014489. The incident occurred 02/29/2024 and the incident report was received by the Department on 02/29/2024. LPA met with Chief Program Officer, Joe Ford and discussed the incident. During this visit, LPA conducted a confidential interview. LPA was unable to interview client as client was at school. Additional interviews will be conducted on a later date. LPA requested copies of the following documents: LIC 500 and Client Roster. Based on interview and information gathered, this case management needs further investigation. Exit interview was conducted, and a copy of this report was emailed to the Chief Program Officer.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Dahl Larios conducted a case management inspection March 14, 2024, at 10:18 am based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 5 out of Direct Care Staff and 5 out of 16 youth files were reviewed. 3 out of Direct Care Staff and 3 out of 16 youth were interviewed. (See the Confidential Names List, LIC 811, dated March 14, 2024). The Plan of Operation including policies and procedures were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth case plans, 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 Dahl Larios 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 Assistant Vice President Timothy Lin.


summary: Facility Evaluation

raw_content:
Narrative:
On May 21, 2024, Licensing Program Analyst (LPA) C. White made an unannounced visit to Hathaway-Sycamores Child and Family Services, for the purpose of conducting a Follow up Case Management for Special Incident Report #1026289. The incident occurred 04/03/2024 and the incident report was received by the Department on 04/08/2024. LPA met with Chief Program Officer, Joe Ford and discussed the incident. During this visit, LPA conducted confidential interview. LPA was unable to interview client as client was not present during visit. Additional interviews will be conducted on a later date. LPA requested copies of the following documents: medical documentation, CFT notes, and confirmation of removal for client #1 showing date of discharge. Based on interview and information gathered, this case management needs further investigation. Exit interview was conducted, and a copy of this report was emailed to the Chief Program Officer.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward met with Ms. Maberry to deliver revised findings for complaint #34-CR-20230315162312.


summary: Facility Evaluation

raw_content:
Narrative:
On 11/15/2024, Licensing Program Analysts (LPA's) C. White and J. Armstrong made an unannounced visit to the above facility for the purpose of conducting an Annual/Required Inspection. LPA's met with Administrator, Tasian Taylor and Assistant Vice President, Timothy Lin. The facility is licensed to care for 16 children ages 11 to 17 and non-minor dependents, ambulatory only. At the time of today's inspection, the census was 13. The Facility is in a residential area and is set up as follows: Administrative Office, Circle M Building, Rowland Cottage, a Dining Hall, Maintenance Room, Music Room, a Recreation room, and Family Cottages. Administrative Office: contains a receptionist area, 10 staffing offices, a board room, 2 bathrooms, and a staff's kitchen. Circle M Building: contains the nurses office, therapy room, mental health staffing offices, multiple cubicles, security office, 2 bathrooms, and a staff kitchen. Rowland Cottage is separated into two halls: Hall A and Hall B: Each hall contains a dining area, a kitchen, 8 bedrooms, two bathrooms, a staffing office, a common area, and a laundry room. Dining areas: have a rectangle tables and multiple chairs. Kitchens: are equipped with a refrigerator/freezer, a 4-burner gas stove (all operable at the time of inspection), a microwave, and dishwasher. Bedrooms: each bedroom is equipped with one (1) twin size bed. All bedrooms were observed to have beds in good repair, pillows, clean linen, adequate drawers, closet cabinets equipped with locked container, and lighting. Bathrooms: one bathroom is for staff and one bathroom for clients. Client bathrooms contain two showers, two toilet stalls and two sinks. Report continued on LIC 809C. Staffing Office: is equipped with a desk, chair, computer, and storage cabinets observed to contain individual storage boxes for each client, and hygiene items. Sharp knives, soap/detergent, and disinfectants are also kept locked in the staffing office and made inaccessible to clients. Common area: contains a mounted television and ample seating. Laundry room: contains a washer, dryer, and storage cabinets with extra linen supplies. All prescribed medications, including medications requiring refrigeration, are locked and centrally stored in the Nurse's Office, located in the Circle M Building. There are no weapons or bodies of water on the premises. The outdoor area contains a basketball court, baseball batting area, swings (area is cushioned with wood chips), outdoor exercise equipment (securely anchored to the ground), and a picnic area. Smoke alarms and carbon monoxide detectors were tested and found to be in working order. There are multiple regulation fire extinguishers located throughout the facility and in each cottage. First Aid kits checked and found to be complete. Overall LPA's observed the facility to be clean, safe, sanitary and in good repair. Additional disinfectants/cleaning solutions are stored in the maintenance room and made inaccessible to clients. The facility operates within license conditions and limitations including capacity limitations. LPA discussed and advised the Licensee to ensure the following: Children are supported and encouraged to participate in extracurricular activities. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. Personal Rights, menus, and activities were posted in one each side of the cottages. Transportation: The facility has a total of 5 vehicles to transport clients. LPA inspected 4 out of 5 vehicles and found seat belts and horns in working order, travel first aid kits, and current registration and insurance. Vehicles are insured by Nonprofit Insurance Alliance of CA and expire 11/01/2025. There are cameras on the building which monitor the outer perimeter of the facility. Facility has a camera waiver on file. LPA's will return at a later date to review client and staff records, as well as conduct client and staff interviews. There are no deficiencies observed or cited at this during this inspection. An exit interview was conducted with the Assistant Vice President, and of this report was left at the facility.

met_with: Administrator - Tasian Taylor and Assistant Vice President - Timothy Lin


summary: Facility Evaluation

raw_content:
Narrative:
On 12/06/ 2023 at 9: AM, Licensing Program Analyst (LPA) C. White and J. Armstrong made an unannounced visit to Hathaway-Sycamores Child and Family Services, for the purpose of conducting a Case Management Annual Continuation Inspection. LPA met with Assistant Vice President, Timothy Lin. LPA's were granted access to the facility and provided the requested information. LPA reviewed the following records during the inspection: Client Records: The program currently has a total of thirteen (13) clients. LPA's reviewed five (5) client records and found each record to meet required regulations. Staff Records: The program currently has a total twenty (20) staff. LPA's reviewed a total of seven (7) staff records and confirmed files contained staff qualifications, current CPR/First Aid cards, health screening, and TB test results. LPA's obtained the LIC 500 to verify Staff to Client ratio. LPA reviewed the Facility Profile and Personnel Report and confirmed that personnel have required criminal record clearance: DOJ, FBI and Child Abuse; which meet qualification. LPA conducted interviews with two (2) staff; all clients were at school. This inspection included an overview of required Core Services and Supports and based upon inspection of facility records and interviews of staff and clients. Licensee is meeting all requirements. There were no deficiencies cited per California Code of Regulations and Interim Licensing Standards. Exit interview was conducted, Appeal Rights and a copy of this report was given to the Director of Residential Programs.


summary: Facility Evaluation

raw_content:
Narrative:
On 11/19/2025, Licensing Program Analyst (LPA) C. White made an unannounced visit to the above facility for the purpose of conducting a Required Inspection. LPA met with Timothy Lin, Assistant Vice President. The facility is licensed to care for 16 children ages 11 to 17 and non-minor dependents, ambulatory only. At the time of today's inspection, the census was 12. The Facility is in a residential area and is set up as follows: Administrative Office, Rowland Cottage, Dining Hall, Nurses Office, Maintenance Room, Music Room, a Recreation room, Circle M Building, Family Cottages, and Outdoor Activity Space. Administrative Office: has a reception area, staffing offices, 2 bathrooms, and a staff's kitchen. Circle M Building: contains a therapy room, mental health staffing offices, nurses' office, multiple cubicles, 2 bathrooms, and a staff kitchen. Rowland Cottage: The cottage is divided into two sides, Hall A and Hall B. Hall A: contains a dining area, a kitchen, 8 bedrooms, two bathrooms, a staffing office, and a laundry room. Dining area: has a table and sofas. Kitchen: is equipped with a refrigerator/freezer, a 4-burner gas stove (operable at the time of inspection), a microwave, and dishwasher. Bedrooms: all bedrooms have one (1) twin size beds, drawers, closet cabinets, and working lights. Bathrooms: one (1) bathroom is designated for staff use and one (1) bathroom is for client use. Client bathrooms contain two (2) showers, two (2) toilet stalls, and two (2) sinks. Report continued on LIC 809C (Page 1 of 3) Staffing Office: is equipped with a desk, chair, computer, and two storage cabinets. The cabinets were observed to contain individual storage boxes for each client, additional hygiene items. Additionally, sharp knives, soap/detergent, and disinfectants are kept locked in the staffing office and made inaccessible to clients. Laundry room: contains a washer, dryer, and shelves that store extra linens. Hall B: contains a dining area, a kitchen, 8 bedrooms, two bathrooms, a staffing office, and a laundry room. Dining area: has a table and ample seating. Kitchen: is equipped with a refrigerator/freezer, a 5-burner gas stove (operable at the time of inspection), a microwave, and dishwasher. Bedrooms: all bedrooms have one (1) twin size beds, drawers, closet cabinets, and working lights. Bathrooms: one (1) bathroom is for staff and one (1) bathroom for clients. Client bathrooms contain two (2) showers, two (2) toilet stalls, and two (2) sinks. Staffing Office: is equipped with a desk, chair, computer, and two storage cabinets observed to contain individual storage boxes for each client, additional linen supplies, and hygiene items. Sharp knives, soap/detergent, and disinfectants are also kept locked in the staffing office and made inaccessible to clients. Laundry room: contains a washer, dryer, and shelves that store extra linens. Dining Hall: is equipped with multiple tables and chairs and is attached to the campus central kitchen. The kitchen prepares all meals for clients. The kitchen is equipped with two (2) refrigerators, a walk-in freezer, and a walk-in pantry. The campus maintains more than the minimum two (2) day perishable food and one (1) week nonperishable required food supply. Nurses Office: All prescribed medications, including medications requiring refrigeration, are locked and centrally stored in the Nurse's Office. Outdoor Activity Space: The outdoor area contains a basketball court, baseball batting area, swings (area is cushioned with wood chips), and outdoor exercise equipment (securely anchored to the ground). Transportation: The facility has a total of 5 vehicles to transport clients. LPA inspected 2 out of 5 vehicles and found seat belts and horns in working order, travel first aid kits, and current registration and insurance. Vehicles are insured by Gallagher and expires 10/31/ Report continued on LIC 809C (Page 2 of 3) There are no weapons or bodies of water on the premises. Smoke alarms and carbon monoxide detectors were tested and found to be in working order. There are multiple regulation fire extinguishers located throughout the facility and in each cottage. First Aid kits checked and found to be complete. Hot water was tested and found to be between 105-120 degrees (F). Overall LPA observed the facility grounds to be clean, safe, sanitary and in good repair. Temperatures in client rooms and common areas were found to be between 68 - 85 degrees (F). Additional disinfectants/cleaning solutions are stored in the maintenance room and made inaccessible to clients. The facility operates within license conditions and limitations including capacity limitations. LPA discussed and advised the Licensee to ensure the following: Children are supported and encouraged to participate in extracurricular activities. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. Personal Rights, menus, and activities were posted in each hall. LPA observed cameras in the common areas, and on the outside perimeter of the buildings. The cameras are monitored by the administrative staff and the IT Department. LPA will return at a later date to review client and staff records, as well as conduct client and staff interviews. There are no deficiencies observed or cited during this inspection. An exit interview was conducted with the Assistant Vice President, and of this report was emailed to the facility. (Page 3 of 3)

met_with: Timothy Lin - Assistant Vice President


summary: Facility Evaluation

raw_content:
Narrative:
On December 5, 2025 at 9: AM Licensing Program Analyst (LPA) Connie Jones-Steward made an announced visit to Hathaway-Sycamores Child & Family Services to conduct the Psychotropic Case Medication Inspection. LPA met with Head of Service, Timothy Lin who assisted with the inspection. There are 7 clients who meet the criteria for inclusion in this inspection. LPA was able to complete three client file reviews. LPA will complete the inspection on December 12, 2025.

met_with: Timothy Lin, Head of Service


summary: Facility Evaluation

raw_content:
Narrative:
On December 12, Licensing Program Analyst (LPA) Connie Jones-Steward completed the SB Inspection that began on December 10th. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). Head of Service Timothy Lin assisted with the inspection. LPA reviewed seven (7) client records, including Needs & Services Plan and Psychotropic Medication Records, and three (3) personnel files at the facility. LPA interviewed one staff member. There were no clients available to be interviewed prior to conclusion of inspection. LPA reviewed the facility's procedure for sending medication with clients on home passes and for the destruction of unused medications. LPA also verified that staff are receiving psychotropic medication training as part of their annual training. At the conclusion of the inspection, an exit interview was held with the administrator. No citations were issued during the inspection. This concludes the SB Inspection for 2025


summary: Facility Evaluation

raw_content:
Narrative:
On 1/14/ LPA Reagan Cohen arrived at the above facility to conduct a Case Management - Incident regarding IR Follow Up #1470851 in which a client while at school was involved in multiple CPI restraints and potentially received bruising on the hand. LPA met with Tim Lin Head of Service (HOS) for the facility and interviewed multiple staff regarding the IR. No deficiencies cited. LPA will return to continue the investigation. Exit interview conducted and a copy of this report was given to the HOS.

met_with: Tim Lin HOS


summary: Facility Evaluation

raw_content:
Narrative:
On May 3, 2021, Licensing Program Analyst (LPA) Regina Martin conducted a Case - Management Incident inspection via Microsoft Teams Meeting to deliver and discuss findings from the Department's Investigation on self-reported incident SIR #710958, dated August 8, 2020. LPA met with Daisy Delgado, Director of Residential Programs. On August 9, 2020, Community Care Licensing received an incident report reporting assaultive behavior by Staff #1 (S1) on Client #1 (C1). It was reported in part, that S1 and C1 were involved in a physical altercation resulting in injury to C1. The incident was referred and assigned to Investigations Branch, Investigator, Dennis Seng. The investigation including confidential interviews, review of related records and review of facility video surveillance footage revealed evidence to support physical abuse by S1 on C1. On August 8, 2020, during an altercation outside of the facility Cottage, C1 became upset that S1 confiscated a portable speaker from C1 for refusing to lower the volume after being asked by S1 to lower it several times. C1 attempted to retrieve the speaker from S1; however, S1 refused to return the speaker to C1. C1 "flicked," S1's hat and pushed him. S1 pushed C1 back and a physical altercation ensued between them. Staff #2 (S2) intervened and separated both parties. C1 was led to Program Support (PSS). After sitting at PSS for several minutes, C1 ran back to the Cottage and pushed S1 again. S1 pushed C1 back and another physical altercation ensued between parties. S2 ran back to the Cottage and separated both parties. Both altercations were captured on surveillance footage. (Continued on page LIC809-C) C1 was checked by the facility nurse and later taken to the hospital for further assessment. Medical records revealed C1 was hit with fists several times and placed in a chokehold, sustaining mild swelling and a brief loss of consciousness. After the altercation S1 left the facility and never returned. On August 9, 2020, S1 called the facility to officially resign from his position. Upon occurrence, the facility contacted all required parties and conducted an internal investigation pertaining to the incident. Corrections concerning facility policy and procedures pertaining to this incident were reviewed and updated as necessary. Based on gathered information there is corroborating evidence to support claims of abuse. The preponderance of evidence standard has been met and the Department has therefore determined substantiated findings for physical abuse by S1 on C1 as evidence revealed S1 failed to de-escalate the situation or call for assistance in controlling C1's behavior. S1's actions on C1 poses an immediate health, safety and personal rights risk of harm to children placed in care. The facility is issued a citation in accordance with the Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards, Chapter 7.5, Version 3.1; 87072 (d)(11) Personal Rights. See page 809D for deficiency. Exit interview conducted; Appeal Rights issued, and a copy of this report will be emailed to Ms. Delgado for signature.

met_with: Daisy Delgado


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On August 23, 2022 at 9:00am Licensing Program Analysts (LPAs), Emelyn Sanchez P. and Olivia Rosas arrived at the above facility unannounced for the purpose of conducting a SB Psychotropic Medication Case Management- Medication Inspection Visit. LPAs Sanchez P. and Rosas met with Daisy Delgado, Director of Residential Programs and Julie Farino, Assistant Director Medication Support. LPAs Sanchez P. and Rosas reviewed nine (9) client files and three (3) staff files. LPAs Sanchez P. and Rosas conducted one (1) client interview and three (3) staff interviews. Currently there are twenty-six (26) clients residing in the above facility. During the review of client records, LPAs Sanchez and Rosas observed that 9 out of the 9 client records had no updated Needs and Services Plan (NSP) within the 30 day period from the last NSP conducted. This is a facility located in a residential area and equipped with a kitchen/dinning room, three cottages that have a living room, laundry space, small kitchen, bathrooms and bedrooms. There is also an Art Room, Recreational Hall, Medication Office, an outdoor BBQ patio, and basketball court. Outdoor space is free of obstructions. LPAs Sanchez P. and Rosas observed the facility to be clean, safe, sanitary and in good repair. LPAs Sanchez P. and Rosas observed adequate staffing in the facility to provide care and supervision to children in care. LPAs Sanchez P. and Rosas also observed medication to be centrally stored, triple locked and inaccessible to clients and unauthorized staff members. The following deficiency was cited per Interim Licensing Standards for STRTP Version 4 87068.3. Exit interview was conducted, and a copy of this report was left at the facility.

Deficiencies:
87068.3(a): (...).

met_with: Director of Residential Programs

title:
1
2
3
4
5
6
7(a) The needs and services plan specified in Section 87068.2 shall be updated at least every 30 days to determine the following


summary: Facility Evaluation

raw_content:
Narrative:
On 1/29/26, LPA Reagan Cohen arrived at the above facility office location for the purpose of conducting a case management incident visit. LPA met with Administrator Tasian Taylor regarding IR Follow Up for IR #1470851, in which a client, while at school, was involved in multiple CPI restraints and potentially received bruising on the hand. During the course of the investigation, LPA interviewed involved staff, witnesses, and clients. Witness interviews shared that C1, before the incident, was acting irritable and uninterested in the class. C1 tried to elope from the class, the school staff responded by trying to discourage C1 from leaving and blocking the path. C1 then tried to hit school staff multiple times. The staff responded by performing at least 2 separate CPI restraints on C1 for their safety and the safety of others. C1 eventually calmed down and was released from the restraint. The incident happened at the school, so the facility was informed. Facility staff testified to responding by trying to check in on and with C1. Both the facility nurse and clinician attempted at least twice to check in with C1 regarding the incident. Both times, for both staff, C1 refused to discuss the incident and refused any sort of medical check-up or hospital visit. The facility nurse stated that while she was not able to perform a full medical check-up, she did not observe a bruise on the client's hands and observed the client being able to perform normal physical activities without discomfort. When interviewing the client, C1 confirmed that the incident and restraint happened. C1 stated that the restraint was not unfair and admitted to trying to leave the classroom. C1 did not share much, but did state that they were not hurt and that they did not want any follow-up. Based on the evidence presented from both staff, witnesses, and client interviews, while the incident did happen and a restraint was performed by school staff, the facility had the appropriate response and offered options to the client, including medical and mental health attention. The facility tried multiple times and each time C1 refused service. Because of the evidence presented no deficiencies are being cited at this time. LPA presented and discussed the findings with the Administrator Tasian Taylor Exit interview conducted, and a copy of this report was given to the Facility.

met_with: Administrator Tasian Taylor


summary: Facility Evaluation

raw_content:
Narrative:
On February 25, 2025 at 1:30pm Licensing Program Analyst (LPA), Emelyn Sanchez P. made an unannounced visit to Hathaway-Sycamores Child and Family Services for the purpose of conducting a Follow-up Case Management- Incident visit regarding a medication administration error. LPA Sanchez P. met with Tasian Taylor, Administrator and Timothy Lin, Head of Service to discuss the incident. The special incident report was reported to the Department on 02/17/2026. The incident occurred on 02/16/2026. The incident stated that the child was given a PRN medication in close proximity to a prior dosage. During this visit, LPA Sanchez P. conducted confidential interviews with staff and client in care. LPA Sanchez P. requested copies of the Personnel Report (LIC 500) and Client Register. LPA Sanchez P. also obtained copies of the client's Medical Report follow up. Based on interviews and information gathered no deficiencies are being cited at this time. . Exit interview was conducted, and a copy of this report will be e-mail to Tasian Taylor, Administrator and Timothy Lin, Head of Service.

met_with: Tasian Taylor, Administrator


facility_name: HAYNES FAMILY OF PROGRAMS

raw_content:
Narrative:
Continue from page 1 . . . . The staff denied the allegations and stated that the clients are made to do a self search when coming back to the facility from the community by putting their pockets inside out, taking off their shoes, shaking their clothing and opening their backups to prevent drugs from coming into the facility. The staff indicated that room searches are done when there is a suspicion of drug possession by a client and that the staff uses a dog to inspect the facility. The staff indicated that the staff does not make inappropriate comments toward the clients and that the staff have not threatened to hit clients. The staff stated that the clients curse or threaten the staff and know what the staff is able to do. The confidential interviews indicated that the clients are made to do a self search when they come to the facility, statements were obtained indicating that the clients empty their pockets, take of their shoes and shake their clothing when coming back form AWOL or the community. The confidential interviews indicated that the clients curse and threaten the staff and that the staff have not made inappropriate comments toward the clients or attempted to hit the clients. The social workers were not available to give a statement regarding the allegations. There was no corroborating information obtained through interviews to confirm the allegations. Based on the information obtained though interviews the allegations are found unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the allegations occurred, therefore, the above allegations are Unsubstantiated. Appeals rights were provided and discussed with the facility representative mention above. There were no deficiencies cited. An exit interview was conducted, and a signed copy of this report was left with above staff.

Investigation Findings:
13On September 21, 2021, Licensing Program Analyst (LPA) Heriberto Perez conducted a follow-up complaint inspection to the above facility and and met with William Sanchez, Campus Manager. The purpose of the inspection was to deliver the finding for the above complaint allegations. During the course of the investigation, LPA interviewed one two staff via telephone on 09/09/21, LPA interviewed one staff via telephone on 09/10/21, LPA interviewed one client via telephone on 09/16/21 and LPA interviewed two clients via telephone on 09/17/21 (see Confidential Names Form LIC 811 dated September 21, 2021). It was alleged that the Staff allow minors to bring drugs into the facility, Staff make inappropriate comments towards minors and Staff threatened to hit minors. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Heriberto 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 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: HAYNES FAMILY OF PROGRAMSFACILITY NUMBER: VISIT DATE: 09/21/2021

met_with: William Sanchez, Campus Manager


raw_content:
Narrative:
Client digitally penetrated staff and client was orally copulated by staff. Records confirm dates and time client and staff were together. Staff allowed client to reside with staff and engaged in continued sexual abuse of client, when client went AWOL. Evidence obtained during the investigation such as the description of the staff's home, bedroom, vehicle, personal belonging, identifying mark, and social media accounts and text messages support the allegations. Based on information obtained during the investigation, there is a preponderance of evidence found so the allegations are substantiated. Deficiency citations are issued under Interim Licensing Standards for STRTP (v3.1) 87072(d)(11) Personal Rights. A copy of this signed report and a Plan of Correction was discussed with the facility representative. Copies of the following reports: LIC 9099, LIC 9099C, LIC 9099-D and the LIC 811 (Confidential Names Form dated 9/21/21) were provided at the conclusion of the inspection. Specific dates were unknown and there was no evidence or witness found to corroborate the allegations. No statement was obtained from the former staff whose whereabouts are unknown. Based on information obtained during the investigation, the allegations are unsubstantiated. Although the allegations may have happened or are valid, there is no preponderance of evidence found to prove or disprove that the allegations occurred. An exit interview was conducted. A copy of this signed report, the Confidential Names Form dated 9/21/21 and Appeal Rights forms were provided. There were no deficiencies cited for the above allegations.

Investigation Findings:
13On September 21, 2021, Licensing Program Analyst (LPA) Irene Yamamoto delivered the findings of the allegations at the facility and met with the facility representative named above. The complaint was investigated by Investigations Branch (IB) Investigator Lorraine Patterson who reviewed pertinent documents from client and staff records and conducted confidential interviews. Records reviewed include, but were not limited to, Client: Intake Assessment, Identification and Emergency Information, Placement Agency Agreement, Individual Safety Plan, Incident Reports, Needs and Services Plan, Discharge Summary and Staff: Application, Training Records, Criminal Record Clearances, Employee Performance Review and various signed workplace acknowledgements including terms and conditions related to child abuse, professional boundaries and position description. Investigator Patterson also reviewed law enforcement reports. It was alleged that staff sexually abused client while in care and engaged in conduct inimical which presented a risk to clients in care. Confidential interviews reveal that the sexual abuse occurred multiple times on facility grounds, when client and staff went for one on one walks after dinner. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Irene Yamamoto LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: HAYNES FAMILY OF PROGRAMSFACILITY NUMBER: VISIT DATE: 09/21/2021

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

met_with: Jazmin Roybal, Quality Assurance Coordinator


raw_content:
Narrative:
On 05/11/2022, the Department received a complaint alleging allegation for personal Rights violation. It was alleged that a staff worker engaged inappropriately with a client of being in a relationship. Staff workers assigned to the cottage where the client was identified as being the alleged victim denied the allegation. All staff workers stated that there is no inappropriate activities occurring among staff and clients. In confidential interviews, all clients that were interviewed denied the allegation and stated that all staff workers are respectable and they have never committed any sexual advances towards them. One client admitted to saying things that were not true while at school about being in a relationship with a female staff. The one client stated that "it's just talk" and stated he never had any form of sexual contact with that one staff. Individual identified as other is deemed to be a credible witness who stated that the allegation that was overheard by the one client is accurate when first reported. The County Probation Office representative met with the one client and determined that there were no concerns and no further action was required but will follow up with Licensing Program Analyst Vargas's investigation. Interviews by the clients provided consistent statements and denied the allegation. However, one client admitted to saying that he was having a relationship with a female staff but he was "just talking" to others while attending school off-site. Therefore, the above allegations are determined unsubstantiated at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged abuse occurred. The resolution to this complaint was discussed with the agency representative and copies of all licensing reports were provided at the conclusion of the inspection. An exit interview was conducted and the Appeal rights given were and explained. No deficiencies were cited at this time.

Investigation Findings:
13On 09/20/2022 at 10: AM, Licensing Program Analyst (LPA) Joseph Vargas conducted a follow-up inspection for the purpose of providing findings for the above complaint. LPA met with Ms. Jasmin Royball, Quality Assurance Coordinator. During the course of the investigation, LPA conducted in-person visits, and telephone interviews with two staff workers, five clients, LA County Probation Officer (PO), individual identified as other on 05/13/2022, one staff worker on 5/12/22, one staff worker on 5/16/22, and one staff worker on 5/14/22 (reference confidential names list LIC811 dated 09/20/22). During the inspection, LPA Vargas requested for review and obtained copies of the staff and client files such as client roster, staff roster (LIC500), current Needs and Service Plan (NSP), medical documents (JV-223) and special incident reports (SIR). LPA Vargas researched any prior history of complaints similar to this investigation. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Joseph Vargas LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: HAYNES FAMILY OF PROGRAMSFACILITY NUMBER: VISIT DATE: 09/20/2022

met_with: Ms. Jasmin Royball, Q.A.


summary: Facility Evaluation

raw_content:
Narrative:
On October 29, 2021 at 10: AM, Licensing Program Analyst (LPA) Irene Yamamoto conducted a case management inspection at the facility in order to assess an Enhanced Civil Penalty (ECP). LPA Yamamoto met with the facility representative named above and discussed the following: On 3/4/21, the Department received a complaint that staff sexually abused client in care and engaged in conduct inimical to clients in care. Confidential statements obtained during the investigation revealed that the sexual abuse occurred multiple times on facility grounds when client and staff went for one on one walks. Staff orally copulated client and staff allowed client to digitally penetrate staff. Records obtained show the dates and times client and staff were together. Based on this evidence, the complaint was substantiated, and the facility was cited on 9/21/21 under Interim Licensing Standards 87072(d)(11) Personal Rights. The Department has concluded an analysis and determined that an Enhanced Civil Penalty (ECP) is warranted. Per Health and Safety Code section 1548(2), "physical abuse" includes sexual abuse as defined by Penal Code section 11165.1 which includes Section 288a oral copulation. For a violation that the Department determines resulted in the sexual abuse of a person receiving care at a short-term residential therapeutic program, a civil penalty shall be assessed in the amount of $ 5,000.00 for a facility licensed to care for 41 to 100 children. A copy of this signed report, Confidential Names Form (LIC 811), Appeal Rights and Form LIC 421-D (CRP) Civil Penalty Assessment - Death / Serious Bodily Injury / Physical Abuse were provided to the facility representative.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) T. Davis went to Haynes Family of Programs on December 08, 2021 at 9:15am for the purposes of an unannounced Required Annual Inspection. The facility is a Short Term Residential Therapeutic Program (STRTP) that is licensed to serve seventy-two (72) male clients ages 12-17 years old. LPA met with William Sanchez, Campus Manager (CM), and together they toured the facility inside and outside. The STRTP is located in a residential neighborhood and presently has clients placed in two cottages (Wittryand Burton). As of today's inspection, Wittry has eight clients in placement and Burton has eight clients in placement as well. Overall, there are sixteen clients currently in placement at the facility. LPA observed the kitchen in each cottage to be clean and well stocked with several food items (perishable and nonperishable). Sharp knives and cleaning supplies are kept locked in areas inaccessible to clients. The bathrooms in each cottage were observed to be in good repair and working order. The bedrooms contained twin beds, desks, and closet space. Medications are kept locked in the Health Services office. The facility has designated six vehicles for client and STRTP related purposes. Exit signs were visible in both of the abovementioned cottages. LPA obtained a current copy of the facility's staff roster (LIC500) and client roster. The last fire drill was held on August 26 2021 at 9:30am. The CM stated that there were no guns or weapons on the premises. LPA reviewed four client files and three staff files and found the reviewed files to be in order. There is a properly secured in-ground swimming pool on the premises enclosed with a self-latching gate. There is adequate seating in each cottage's dining area and living room. All exits were free of hazards and all doors opened freely. The CM provided LPA with copies of the minutes from the Board of Director's meetings that were held on November 18, 2021, September 23, 2021 and July 29, 2021, respectively LPA interviewed clients and staff during today's inspection. LPAs found no Title 22/ILS deficiencies on this date. Exit interview conducted


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) T. Davis went to Haynes Family of Programs on December 08, 2021 at 9:15am in order to follow up on a Special Incident Report (SIR) that was submitted to Community Care Licensing on November 10, 2021. LPA met with William Sanchez, Campus Manager (CM), and discussed the incident. The SIR stated that child #1 (see Confidential Names form (LIC 811) dated December 08, 2021) took a lighter from his pocket and proceeded to light the facility's security camera. During the course of the follow up, LPA obtained information that staff was providing care and supervision at the facility. During a routine accountability check, staff observed the security camera on fire that was located in the corner of the upstairs hallway. Staff investigated the matter and it was determined that child #1 had used a lighter to set the facility's security camera on fire. Staff was unsuccessful in their efforts to get child #1 to empty his pockets. Based on information and facts obtained in this matter, the Department has found that the child was in a gang and struggled with his program while in placement at the facility. The child was able to sneak the lighter into the facility unbeknownst to the staff. Information shows that the child is no longer placed at the facility. Therefore, the situation has been stabilized and no citations will be issued on this date. No further follow up is necessary. Exit interview done


facility_name: HAZEL'S SAFE PLACE

summary: Facility Evaluation

raw_content:
Narrative:
On March 7, 2024 at the Fresno Regional Office an informational meeting was conducted. The Meeting was to go over the current application information including the financial sections, Plan of Operation and Program Statement. The meeting was attended by Licensing Program Manager Lourey Bartolome and Licensing Program Analyst Leslie Inouye. Hazel's Safe Place was represented by Board Members Odoom Domson and Hazel Domson. . Application supporting documentation information was discussed to determine missing required information, program consistency and to verify information in the application. The meeting is also to resolve any questions, and determine whether the facility is capable of providing the services specified for a Short Term Residential Treatment Program. During the meeting it was determined and agreed that the applicants will review, update and resubmit the application. The application submission due date will be Friday April 5, 2024 at close of business day. If there are any questions or clarification that needs to be discussed the applicants will contact LPA Leslie Inouye. Any changes or modifications to the due date shall be in writing prior to April 5, 2024.

met_with: Hazel Domson and Odoom Domson


facility_name: HAZEL HOUSE

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

met_with: Dekeydra Mothershed


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13Licensing Program Analysts (LPA's) Reyna Martinez and Lidia Tinoco conducted a complaint inspection and met with Dekeydra Mothershed. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the investigation, LPA conducted interviews, conducted a record review, and reviewed supporting documents provided by the facility. Based on the information obtained during review of documentation, the preponderance of the evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The California Code of Regulations 80087(a) Buildings and Grounds are being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report and appeal rights were provided at the end of the inspection. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Reyna Martinez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SIERRA CASCADE AC/SC, E SHAW AVE FACILITY NAME: HAZEL HOUSEFACILITY NUMBER: 107202385

complaint_status: SUBSTANTIATED


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

met_with: Quentious Addison


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Jessica Rodriguez conducted a complaint inspection and met with Administrator, Dekeydra Mothershed. The purpose of the inspection was to deliver the findings for the above complaint allegations. During the investigation, LPA conducted interviews and a record review and reviewed supporting documents provided by the facility. Based on the information obtained a preponderance of the evidence that the allegations occurred as reported could not be found. Although the allegations may or may not have happened, or are not valid, there is not a preponderance of the evidence to prove the alleged violations did or did not occur, therefore the allegations are deemed unsubstantiated. An exit interview was conducted, and a copy of this report and appeal rights were provided to the Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Jessica Rodriguez 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: 3 of 6