summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 10/19/22, Licensing Program Analyst (LPA) Mariah Hawkins conducted an inspection continuation from the initial visit conducted on 10/6/22. LPA met with Administrator Nina Davis and informed of the purpose of the visit. LPA used the CARE Inspection Tool to conduct the inspection. During inspection, LPA conducted interviews with three staff and three residents and conducted a review of resident records. The following deficiencies were found: The admission agreement in resident R1's (See LIC 811) file is not signed by the authorized representative. The needs and services for R1 and R2 for May 2022, June 2022, July 2022, and August 2022 are not in the files. The needs and services for R3 and R4 for August 2022 are not in the files. The needs and services for R5 is not in the file, nor a pre-placement, and the resident has been in care over 30 days. The needs and services for R1, R2, R3, and R4 for September 2022 are not signed by the residents nor authorized representatives. The needs and services for R1 for April 2022 and March 2022 are also not signed by the resident and authorized representative. LPA is issuing citations of Title Section 80070 and STRTP ILS Sections 87068.2 and 87068.3. See attached LIC 809-Ds. A phone policy to have personal phones turned in at 9PM is not documented in the needs and services and signed off by the authorized representative. LPA advises that the facility document this in the needs and services plans for each youth with personal phones and get authorized representatives' approval. A continuation inspection will be conducted to complete the file review. An exit interview was conducted, appeal rights provided, and a copy of this report provided to Administrator Nina Davis, whose signature on this form confirms receipt.

Deficiencies:
87068.3(a): Modifications to The Needs And Services Plan

(a) The needs and services plan specified in Section 87068.2 shall be updated at least every 30 days to determine the following


state: CA

facility_name: LIGHTHOUSE MENTORING CENTER 2

summary: Facility Evaluation

raw_content:
Narrative:
On 10/19/22, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility for a case management visit. LPA met with Administrator Nina Davis and Facility Manager Keylai Boughton and informed of the purpose of the visit. The purpose of the visit was to conduct confidential interviews with staff and residents about facility operations, which was discussed further with the administrator. Based on interviews with residents and staff, there are no concerns of staff being aggressive or inappropriate with residents, and no deficiencies related to staff conduct have been observed. An exit interview was conducted, and a copy of this report was left with Administrator Nina Davis, whose signature on this form confirms receipt.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Administrator Nina Davis; Facility Manager Keylai Boughton


summary: Facility Evaluation

raw_content:
Narrative:
On 12/14/22 at 11:10AM, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit to complete a file inspection as part of the annual (post-licensing) inspection. LPA met with Administrator Nina Davis and Facility Manager Keylai Boughton and informed of the purpose of the visit. There were two staff present, including Administrator, and LPA has already completed interviews with both. There are no residents present. LPA used the CARE Inspection Tool to complete the inspection. LPA inspected facility records and 5 personnel files and conducted a follow-up inspection of resident files. Based on observation and record review, the below items require follow-up. Staff S2 (See LIC Confidential Names, dated 12/14/22) has been designated a facility manager and has appropriate training. However, S2's file does not contain a bachelor or higher degree, and the LIC 501 does not list education or experience to meet the requirements for the position, including experience in social work or with the population to be served. LPA is issuing a citation of Short-Term Residential Therapeutic Program Interim Licensing Standards, Section Personnel Requirements. See attached LIC 809-D. The file for staff S1 (See LIC 811) does not contain the initial training record or the facility manager job duties. Additionally, S1 last received intervention training on 4/21/21, per the training log, and has 27 hours of training to complete by February 2023. See attached advisory notes (LIC 9102). An exit interview was conducted, appeal rights provided, and a copy of this report was provided to the facility. Administrator Nina Davis's signature on this form confirms receipt.

met_with: Administrator Nina Davis, Facility Manager Keylai Boughton


summary: Facility Evaluation

raw_content:
Narrative:
On 12/14/22 at 2PM, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit at the facility. LPA met with Administrator Nina Davis and Facility Manager Keylai Boughton and informed of the purpose of the visit. Per the noncompliance conference (NCC) held on August 8th, 2022, the facility will be subject to increased inspections, will submit a LIC 500 on a quarterly basis, will provide updates on pursuing designating different administrators for all facilities under licensee, and will provide staff training and reminders, documenting everything, on all required topics, including supervision, facility policies and procedures, communication, personal rights, and emergency intervention. During visit, LPA inspected facility, resident, and personnel files. LPA received the submitted LIC 500. The facility has not yet been able to designate a separate administrator for each house but will continue to provide updates. The second house that Administrator Nina oversees is temporarily closed, so for the time being, Administrator is only overseeing one facility. Staff training is well documented, but some issues were observed. LPA observed that one staff member was designated a facility manager, but their file did not reflect they were fully qualified for the role. Additionally, another staff file reflected that the staff member had not received emergency intervention training since April 2021 and had 27 hours of training to complete by February 2023. LPA issued citations and advisories for these during a post-licensing inspection completed on this same day. As such, additional citations/advisories are not included as part of this report. No other deficiencies were found. An exit interview was conducted, and a copy of this report was provided to the facility. Administrator Nina Davis's signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 6/23/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit at the facility. LPA met with Administrator Nina Davis and informed of the purpose of the visit. Per the noncompliance conference (NCC) held on August 8th, 2022, the facility will be subject to increased inspections, will submit a LIC 500 on a quarterly basis, will provide updates on pursuing designating an administrator to be the administrator of only one facility, and will provide staff training and reminders, documenting everything, on all required topics, including supervision, facility policies and procedures, communication, personal rights, and emergency intervention. During visit, LPA inspected facliity files and conducted confidential interviews with staff and residents. LPA received the current LIC 500. The licensee is in the process of designating an administrator who will not oversee any other facility, and the candidate has already been approved by community care licensing. LPA observed staff training to be well documented and reflect that staff are receiving training on the required topics. Staff reviewed have met or well-exceed the required hours. LPA observed the facility to be clean and living spaces to be tidy. Personal rights and house rules are clearly posted. LPA observed staff and residents to engage well with each other. Grievance procedures and the numbers for the ombudsperson's office and community care licensing are posted. No deficiency citations were issued at today's visit. An exit interview was conducted, and a copy of this report was provided to Administrator Nina Davis, whose signature on this form confirms receipt.

met_with: Administrator Nina Davis


summary: Facility Evaluation

raw_content:
Narrative:
On 8/28/2023 at 11: AM Licensing Program Analyst (LPA) Shikya Belfield conducted an announced visit to the above licensed facility. The purpose of this visit is to conduct the Psychotropic Medications inspection. LPA met with administrator Nina Davis who assisted with the inspection. At the time of the inspection, there were two staff, and the administrator. The facility currently has five clients, three were at school, one was on a home visit, and one client was in the facility after an appointment. LPA reviewed the files of two staff however, training's were located in a separate binder observed by LPA Belfield. During a review of the training's LPA Belfield did not observe training specific to psychotropic medication. Administrator states that the person in charge of the training files will send the training to this LPA via email. LPA agreed to this. LPA Belfield interviewed two staff members. The facility's current census is five clients, three of whom are currently prescribed psychotropic medications. Three client files were reviewed. LPA also reviewed the centrally stored and medication logs as well as Psychotropic Medication Administration Record for each client. Based on record review, LPA Belfield observed that one of the psychotropic medications for C2 ( see LIC 811 dated 8/28/23), are being documented incorrectly and it is the wrong dosage is being administered to the client. Facility will be cited for violation of Interim Licensing standards, section 87075(c) Health related services. LPA Belfield observed staff conduct a pill count of the psychotropic medications for each client. There were missing pills for C2's medication was noted during the medication log review. Facility will be cited for violation of 87075(c) Health related services. During a review of the Psychotropic Medication Record, it was observed that the medications required information was present, however it was incorrect such as refill information. This is a violation of California Code of Regulations (CCR) 84070(b)(13)(c). Technical Violation Advisory issued. During a review of the client file LPA Belfield observed that the needs and service plans do not have clients signatures and there is no documentation to prove that clients are offered the opportunity to participate in the development of the needs and service plan. Technical Advisory issued for Interim Licensing Standards, section 87068. Needs and Services Plan. All citations and advisories described on the following page D, during the completion of this inspection at a later date. Due to time restraints and needed documentation, this inspection is incomplete and will be completed at a later date.

met_with: Nina Davis


summary: Facility Evaluation

raw_content:
Narrative:
On 9/29/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a required annual inspection. LPA met with Administrator Nina Davis and informed of the purpose of the visit. During inspection, LPA toured the facility and inspected facility records. Three residents were at school, and one resident was on an unauthorized absence. Using the CARE Inspection Tool, LPA found no deficiencies. The facility is maintained in safe condition, and no hazards were observed. There is plenty of food within date, and bathroom and kitchen spaces are in sanitary condition. Files were observed to be complete, staff have background clearances, and training records are complete. A continuation inspection is required to complete this inspection. An exit interview was conducted, appeal rights discussed, and a copy of this report was left with Administrator Nina Davis, whose signature on this form confirms receipt.

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
On 10/6/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted an annual continuation inspection. LPA met with Administrator Nina Davis and informed of the purpose of the visit. LPA interviewed two residents and two staff. One resident was at school, and one was away from the facility. Based on interviews, no deficiencies were observed or reported. Additionally, no deficiencies were found using the CARE Inspection Tool. An exit interview was conducted, and a copy of this report was left with Administrator Nina Davis, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 10/19/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit and met with Administrator Nina Davis. LPA informed that the purpose of the visit was to conduct a quarterly inspection, per the agreed upon terms of the noncompliance conference (NCC). LPA reviewed staff training records and confidential interviews. LPA observed staff to have complete training records, including annual training, initial/orientation training, intervention procedures, and trauma-informed care. LPA provided verbal reminder about staff training hours. LPA discussed staff performance, performance evaluations, and write-up procedures with Administrator. Additionally, the facility has designated an administrator who oversees only one facility. No deficiency citations were issued at today's visit, and there are no outstanding plans of correction (POCs). An exit interview was conducted, and a copy of this report was left with Administrator, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/18/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit and met with Facility Manager Danielle Rosenbaum. LPA informed that the purpose of the visit was to conduct a quarterly inspection, per the agreed upon terms of the noncompliance conference (NCC). LPA conducted confidential resident and staff interviews and reviewed resident and staff files. LPA observed files to be complete and training records to reflect that staff are receiving required hours of training. Interviews reflect that staff use trauma-informed methods to intervene and engage with residents. Management staff are ensuring employee performance evaluations are completed. The facility has maintained an administrator who oversees only one facility, and facility managers are designated, qualified, and trained for the role. No deficiency citations were issued at today's visit, and there are no outstanding plans of correction (POCs). An exit interview was conducted, and a copy of this report was left with Facility Manager Danielle Rosenbaum, whose signature on this form confirms receipt.

met_with: Facility Manager Danielle Rosenbaum


summary: Facility Evaluation

raw_content:
Narrative:
On 2/13/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit and met with Administrator Nina Davis. LPA informed that the purpose of the visit was to conduct a quarterly inspection. Per the noncompliance conference (NCC) held on 8/11/22, the facility will be subject to increased inspections, will submit a LIC 500 on a quarterly basis, will provide updates on pursuing designating an administrator to be the administrator of only one facility, and will provide staff training and reminders, documenting everything, on all required topics, including supervision, facility policies and procedures, communication, personal rights, and emergency intervention. LPA obtained a current LIC 500 updated February 2024, which reflects a facility manager on each night shift and two staff with at least one facility manager on day shifts. The facility has an administrator who oversees only one facility and is on site at least 20 hours per week. LPA observed the facility to be clean and living spaces to be tidy. Personal rights poster and grievance procedures are visibly posted. LPA observed all 7 personnel files to reflect training hours are documented, facility managers have received necessary training and have been designated on a LIC 308 form. LPA also observed files to be complete with regular evaluations and corrective action plans. LPA is requesting the following be submitted to LPA by Thursday 2/15/24: Employee evaluations since Jan 2021 and training logs since Jan 2023, as applicable based on hire dates, for staff S2, S3, S4, S5, S6, S7, and S8. See LIC Confidential Names dated 2/13/24. No deficiency citations were issued at today's visit, and there are no outstanding plans of correction (POCs). An exit interview was conducted, and a copy of this report was left with Administrator Nina Davis, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 5/7/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit regarding a submitted incident report. LPA met with Facility Manager Victoria Robertson and informed of the purpose of the visit. None of the involved parties were present at the facility. LPA discussed the incident with Facility Manager Victoria Robertson and obtained staff schedules, staff contact sheet, and a current resident roster with school and authorized representative information. Per the incident report, a resident used inappropriate language toward a staff member, and the staff member responded back to the resident with inappropriate language. Review of the staff member's personnel file reflects that the staff member signed acknolwedging facility procedures and policies to accord residents respect and received training on trauma-informed care practices. The file also reflects that the staff member was written up and counseled. No deficiency citations were issued at today's visit. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Facility Manager.

met_with: Facility Manager Victoria Robertson


summary: Facility Evaluation

raw_content:
Narrative:
On 08/20/24, Licensing Program Analyst (LPA) Celeste Aparicio conducted a required annual inspection. LPA met with Interim Administrator and informed of the Interim Administrator on the purpose of the visit. During inspection, LPA toured the facility and inspected facility records. All residents were at school during the beginning of the inspection. One resident returned to the facility in the afternoon. LPA conducted two staff interviews and attempted to interview one resident. Using the CARE Inspection Tool, LPA found no deficiencies. The facility is maintained in safe condition, and no hazards were observed. There is plenty of food, and facility was maintained at 74 degrees Fahrenheit. Staff and client files were observed to be complete. Staff have background clearances and training records are complete. An exit interview was conducted, and a copy of this report was left with Interim Administrator, whose signature on this form confirms receipt.

met_with: Victoria Robertson


summary: Facility Evaluation

raw_content:
Narrative:
On 08/20/24, Licensing Program Analyst (LPA) Celeste Aparicio made a visit to the facility to conduct the facility's final quarterly inspection, per the agreement established at the Noncompliance Conference (NCC). LPA met with Interim Administrator and informed Interim Administrator on the purpose of the visit. The agreed upon terms were that the licensee would be subject to increased monitoring, and the licensee is to conduct training on any of these topics: trauma-informed care practices, safe vehicle operation, proper de-escalation procedures, and firearm storage and safety. LPA reviewed staff training records. LPA observed complete training records reflecting the required hours being met and the required topics being covered, including trauma-informed care practices and verbal intervention/de-escalation. Based on LPA's observations, record review, and confidential interviews, the facility was observed to be operating in compliance with applicable regulations/licensing standards and the NCC terms. No deficiencies were observed during today's visit, and there are no outstanding plans of correction (POCs). The facility has met the conditions of the 9/23/ NCC and will no longer be subject to noncompliance inspections. An exit interview was conducted, and a copy of this report was provided to Interim Administrator, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 4/16/25, Licensing Program Analyst (LPA) Celeste Aparicio conducted a case management visit to the facility to discuss client safety plans and client's personal rights. LPA met with Administrator, Victoria Robertson and informed the Administrator on the purpose of this visit. During a review of incident reports and conducted confidential interviews, LPA observed staff to be unfamiliar with clients safety plan for an incident that occurred on February 3, 2025. Based on confidential interviews and records review, LPA found that staff had also been monitoring a client's mail. LPA and facility Administrator discussed client safety plans and the protocol for client's mail. Based on LPA's confidential interview, LPA identified no deficiencies. LPA identified one area in which a Technical Assistance would be beneficial, LPA is issuing a Technical Assistance for Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87072(c)(13) Personal Rights. An exit interview was conducted and a copy of this report was left with the Administrator, whose signature on this form confirms receipt.

met_with: Administrator, Victoria Robertson


summary: Facility Evaluation

raw_content:
Narrative:
On 8/5/25, Licensing Program Analyst (LPA) Celeste Aparicio made an announced collateral visit to the facility to conduct a confidential interview. LPA met with Victoria Robertson, Administrator and informed Administrator on the purpose of the visit. During the inspection, LPA conducted one client confidential interview related to an outside investigation. An exit interview was conducted, and a copy of this report was left with the facility.

met_with: Victoria Robertson, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 8/5/25, Licensing Program Analyst (LPA) Celeste Aparicio made an unannounced visit to the facility to conducted a case management inspection to follow-up on a submitted incident report. LPA met with Victoria Robertson, Administrator and informed Administrator on the purpose of the visit. During the inspection, LPA conducted two interviews with 1 staff member and 1 client. LPA attempted 1 client interview, client declined. The purpose of this inspection was to receive more clarification on the incident report received by the department on 7/29/25 and to check in with the clients in care on how the incident was handled by staff. Based on the interviews conducted, LPA identified that the incident was handled appropriately to protect the health and safety of the clients in care. No deficiencies were observed or cited at this time. An exit interview was conducted, and a copy of this report was left with the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On Friday 9/24/21, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the Short-Term Residential Therapeutic Program (STRTP) for an annual continuation inspection. LPA met with Administrator Nina Davis and informed of the purpose of the visit. There were no children present during today's visit. The inspection was initiated on Tuesday 9/21/21. Refer to LIC Facility Evaluation Report, dated 9/21/21. LPA used the Inspection Tool to conduct the inspection. LPA inspected the facility site, conducted interviews with all present staff and residents, and reviewed current staff and client files, including files for recently discharged resident and staff who recently left facility. The facility was observed to be safe and free of immediate hazards. There are no firearms on the premises, per Administrator. Chemicals and medications are properly stored and inaccessible to residents. Medication administration is logged correctly and, based on staff interviews, medication administration procedures are thorough and followed correctly. Facility is maintained at a comfortable temperature. Residents report that the program provides a supportive environment. The facility is operating in accordance with their license. Staff have background clearances and are associated to the facility. The following concerns were observed: LPA observed the following: Sliding door handle broken; curtain rod over sliding door needs to be drilled back into the wall; large tear in living room sofa with stuffing spilling out; broken microwave door and handle; 3 bedroom doors are broken and/or have large holes, and 1 of those doors does not close due to damage; 4 holes in walls upstairs that have not been repaired; lights in the large bedroom's en-suite bathroom were non-functioning, including the toilet room light. Some items are pre-existing, and LPA was advised they would be fixed soon, so the repairs are still in-progress. Damages at site are not determined to cause an immediate risk to residents. LPA issued a citation of Title 22, Section Buildings and Grounds. LPA observed that the needs and services plans for resident R1, R2, and R3 (Refer to LIC Confidential Names, dated 9/24/21) were not available on site for review. LPA was informed by clinician that a needs and services had not been updated for resident R1 since the pre-placement. R1 was placed on 7/2/21. LPA issued a citation of STRTP Interim Licensing Standards (ILS) Section 87068. Modifications to the Needs and Services Plan. Needs and services plans should be updated every 30 days, noting any progress in the youth's case plan and can provide an opportunity to document what, if any, information from outside agencies is still being obtained. LPA observed that documentation of successful completion of training was not maintained in the personnel record for each staff. LPA is unable to verify training and that all hours of initial training and the 40 hours of annual training have been completed if not properly documented/logged. Current records do not reflect that all training was met, including for staff S1, S2, S3, S4, S5, and S6. LPA issued a citation of STRTP ILS Section 87065. Training Requirements. LPA observed that the facility has developed and is using a clearly organized chart for initial training that could be adapted for documenting annual training. LPA observed that the hot water in the upstairs hallway bathroom measured at a high of 154. F, which exceeds the permitted ranged. A hot water warning notice was posted at the sink, complying with Title 22, Section Furniture, Fixtures, Equipment, and Supplies. LPA advises that the facility continue to monitor the hot water temperature at vanity sinks and adjust hot water settings as necessary to ensure temperatures do not go above F. Three citations and one advisory were issued at this visit. An exit interview was conducted, appeal rights provided, and a copy of this report was provided to Administrator Nina Davis, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 4/20/22 at 3PM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility regarding deficiencies that were discovered during an investigation at the facility. LPA met with Administrator Nina Davis and informed of the purpose of the visit. Safety precautions were taken, including mask-wearing and screening call. The investigation was conducted by the Investigations Branch. During investigation, confidential interviews were conducted with residents, staff, and authorized representative, and police report was reviewed. Based on interviews and record review, the following deficiencies were found. Staff S1 (See LIC Confidential Names, dated 4/20/22) used a disallowed restraint technique, by placing resident R1 in a prone restraint, per the program statement emergency intervention plan, which states, "Interventions Never to Be Used... Prone restraint, unless written authorization has been provided by the youth's physician, based upon their prior physical examination of the youth." Based on file review, the facility did not obtain such written authorization documentation, as R1 was not in placement long enough to get a medical and physical assessment. Additionally, the file contains a Health & Education Passport, dated 12/28/21, that lists asthma as one of R1's conditions, which is listed as a risk factor in prone restraints in the Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87095. Emergency Intervention Prohibitions. LPA is issuing a citation of STRTP ILS Section 87022(f) Plan of Operation. During the prone restraint, R1 placed R1's own hands behind their back, and S1 held R1's hands down to keep R1 down in the restraint, as witnessed by S2, and by doing so held R1 in a prohibited restraint. LPA is issuing a citation of STRTP ILS Section Section 87095.01(a)(5) Emergency Interventions Prohibition, which specifically prohibits the use at any time of any restraint that places a child in a prone position with their hands behind their back. LPA also advises, per STRTP ILS Section 87095.66(c) that any restraint requiring two staff, such as prone restraints, must be performed with two staff. Additionally, at visit LPA inspected the personnel record for S1 and found there was no intervention training certificate. The program statement indicates the facility will use Pro-Act, but Administrator stated the facility does not perform restraints. The personnel record does not reflect that S1 was properly trained and certified prior to using the restraint technique, and S1 and Administrator confirmed that S1 has not been trained since working with licensee's facilities. LPA is issuing a citation of STRTP ILS Section 87095.65(a) Emergency Intervention Staff Training. It was also learned during the investigation, based on S1's statements, that S1 made statements to R1 such as, "This is the best home you'll ever be in, don't mess it up." This statement does not align with supported trauma-informed care practices and is emotionally abusive in nature. Staff statement that R1 is "bad for business" also indicates an inappropriate attitude toward R1. LPA is issuing a citation of STRTP ILS Section 87072(c)(11) Personal Rights. Lastly, the incident report submitted by licensee and written by staff S1 for the incident during which S1 performed the prone restraint does not include information about the restraint. As such, Administrator stated she was unaware that a restraint had been performed. The incident report is also lacking detail of the events, does not indicate when staff notified law enforcement or what items were damaged, and includes language (i.e. "verbal judo") that Administrator is unfamiliar with and cannot verify as part of the progam's intervention plan. LPA is issuing a citation of STRTP ILS Section 87095.61(a) Documentation and Reporting Requirements. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Nina Davis, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 3/10/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit at the facility. LPA met with Administrator Nina Davis and informed of the purpose of the visit. Per the noncompliance conference (NCC) held on August 8th, 2022, the facility will be subject to increased inspections, will submit a LIC 500 on a quarterly basis, will provide updates on pursuing designating different administrators for all facilities under licensee, and will provide staff training and reminders, documenting everything, on all required topics, including supervision, facility policies and procedures, communication, personal rights, and emergency intervention. During visit, LPA inspected facility, resident, and personnel files. LPA received the current LIC 500. The facility has not yet been able to designate a separate administrator for each house but will continue to provide updates. An ad has been running, but the licensee has received few applicants and no applicants have met minimum qualifications. Staff training is well documented, and staff are receiving training on the required topics. However, not all staff have received the required 40 hours of annual training. Facility Manager S1's (see LIC Confidential Names List) record reflects that only 13 hours of training was received between February 2022 and February 2023, which is 27 hours short. LPA also notes that Facility Managers S2 and S3 need 23 hours and 16 hours respectively by June 2023. Licensee provided letters sent to staff in December 2022 informing staff of the missing hours and the need to have 40 hours. LPA is issuing a citation of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87065.1 (see attached LIC 809-D). An exit interview was conducted, appeal rights provided, and a copy of this report was provided to the facility. Administrator's signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 9/26/2023 at 10: AM Licensing Program Analyst (LPA) Shikya Belfield conducted an unannounced inspection to the above licensed facility. The purpose of this inspection is to conduct the continuation of the Psychotropic Medications inspection. LPA met with Administrator Nina Davis who assisted with the inspection. At the time of the inspection, there was one staff present S1 (see LIC 811 dated 8/28/2023). The facility currently has four clients, all who were at school during the time of this inspection. During the first part of this inspection conducted on 8/28/2023, due to time restraints and needed documentation that was being sent to the department, the inspection was not able to be completed. The training documentation was sent to this LPA within the following week. Based on review of the training information received and the observations of LPA Belfield during the previous inspection and today 9/26/2023, and confidential interviews conducted, the following citations and advisory will be issued to the facility today and will be described on the following page LIC D. During a review of the staff training received for the staff, Two of four staff did not have training on psychotropic medication S2 and S3 (see LIC 811 dated 8/28/23), facility cited for violation of Interim Licensing Standards Section 87065.1(d)(3)(M) Supervision, Evaluation, and Training Requirements. Administrator did not have required minimum number of hours for psychotropic medication training however, there was two hours of training earned, technical violation advisory issued for of section 87064(a)(1)(B) of the Interim Licensing standards. The facility's current census is four clients, three of whom are currently prescribed psychotropic medications. Three client files were reviewed on 8/28/20203 and one client file was reviewed for follow up today 9/26/20203. LPA also reviewed the centrally stored and medication logs as well as Psychotropic Medication Administration Record for each client. Based on this record review, confidential interviews, and LPA Belfield observed that one of the psychotropic medications for C2 ( see LIC 811 dated 8/28/23), is being documented incorrectly and the documentation is observed having the wrong dosage being administered to the client. It was confirmed that client was receiving double the amount of medication they were supposed to be receiving. Facility is being cited for violation of Interim Licensing standards, section 87075(c) Health related services. A civil penalty is being assessed. LPA Belfield observed staff conduct a pill count of the psychotropic medications for each client on 8/28/2023. There were missing pills for C2's medication during the pill count conducted by the staff on 8/28/2023. Another pill count was conducted for C2 during this inspection today 9/26/2023 the medication count was not correct. Facility is cited for violation of 87075(c) Health related services. LPA observed missing information and incorrect information from the centrally stored medication form and the PMAR form for C2. It was also observed by this LPA that medications listed on the JV220 for C2 are not all listed and administered to the client at the facility. Documented communication between prescribing physician was observed by this LPA. This Medication inspection was conducted on 8/28/2023, 9/26/2023 and concluded on 9/27/2023. An exit interview was conducted and a copy of this report along with appeal rights will be sent to Administrator Nina Davis and Licensee Jay Lightener.


summary: Facility Evaluation

raw_content:
Narrative:
On 06/12/24, Licensing Program Analyst (LPA) Celeste Aparicio conducted a case management visit and met with facility Interim Administrator. LPA informed that the purpose of the visit was to conduct a quarterly inspection. Per the noncompliance conference (NCC) held on 8/11/22, the facility will be subject to increased inspections, will submit a LIC 500 on a quarterly basis, will provide updates on pursuing a designated administrator to be the administrator of only one facility, and will provide staff training and reminders, documenting everything, on all required topics, including supervision, facility policies and procedures, communication, personal rights, and emergency intervention. LPA obtained a current LIC 500 updated May 2024, which reflects a facility manager on each night shift and two staff with at least one facility manager on day shifts. The facility does not currently have a designated administrator who oversees only one facility; however, the Licensee has been providing the Department with updates on pursing a designated administrator for the facility. LPA conducted a walkthrough of the facility and observed the facility to be clean and living spaces to be tidy. LPA observed personal rights poster and grievance procedures to be visibly posted. LPA conducted two staff interviews and reviewed seven personnel training files. LPA observed Licensee provided letters sent to staff informing staff of the missing hours and the need to have 40 hours completed. LPA observed six personnel training files to be complete or in process reflecting the necessary training hours needed to meet the required 40 hours of annual training. One personnel file of the seven personnel training files reviewed, appeared to be incomplete missing 25 hours for the annual training requirement. Report continued on LIC809-C... LPA is issuing a citation of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87065.1(e)(1). See attached LIC 809-D. LPA is requesting the following be submitted to LPA by Tuesday 07/02/24: S6 completed annual. See LIC Confidential Names dated 06/12/24. An exit interview was conducted, appeal rights were provided, and a copy of this report was left with Interim Administrator, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On April 7, 2026, Licensing Program Analysts (LPAs) Celeste Aparicio and Amee Li conducted an unannounced visit to the facility and met with Administrator, Victoria Robertson. The purpose of the inspection is to conduct a case management to address reporting requirements. During the inspection there were three(3) clients and two(2) staff present in the facility. Upon review of the documentation, it was determined that the incident report for the incident date of August 12, 2025, was submitted two days beyond the required seven-day reporting timeframe. As a result, the LPA is issuing a technical violation related to this finding under California Code of Regulations (CCR), Section 80061(b), Reporting Requirements (refer to LIC9102 attached to the report). An exit interview was conducted, and a copy of the report was given to the facility.


facility_name: LIGHTHOUSE MENTORING CENTER 3

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
... stated they drove into the youth to get the youth to move but later denied this in interview with LPA. Based on LPA's review of video footage, R1 placed self on the hood and windshield of the vehicle and was directed by staff to get off of the vehicle. The vehicle appears to be stopped at this time. R1 removes self from the vehicle, and as R1 steps off and away from the vehicle, the vehicle is propelled forward about a foot at approximately 5- MPH. The speed is low but is high enough to indicate the gas was pressed rather than just the brake being lifted. R1's body is very close to the vehicle, and R1's hand is either still on the vehicle or had just been removed. From the driver's side, from where the video is shot, it is not clear that R1 would not be hit by the vehicle. However, R1 does not show signs of being hit. The vehicle's horn is then honked 6 times in succession. There is no apparent purpose for the honking other than perhaps to warn R1 from walking in front of the vehicle as it is now moving. Based on this footage, LPA determines that the staff operating the vehicle did not act appropriately, and their actions put the health and safety of R1 at risk. Individuals should not jump onto vehicles, and individuals should demonstrate extra caution when operating vehicles around others, especially if others are making attempts to place themselves on top of the vehicle. Additionally, during this incident, staff S1 confirmed to police that S1 stated to youth R2 when R2 pulled out a knife, "You're bringing a knife to a gun fight," though S1 later denied this in interview with LPA. Police found an illegally concealed firearm during a search of S1's vehicle. S1 stated to police that S1 did not know at the time that S1's coworker (S2) had put S2's gun in S1's vehicle after extensive damage was caused to S2's vehicle earlier that day. S1 denied brandishing the weapon. Based on involved resident interview, S1 made a statement about not we're fighting but we're shooting. Based on record review and confidential interviews, S1 made a statement to R2 of a threatening nature that was a highly inappropriate thing to say to a child in care at a STRTP facility, as the statement could reasonably be interpreted by the youth as a threat. Multiple charges were filed against S1 by police, including assault with a deadly weapon, criminal threats, and cruelty to a child. The charges were ultimately dropped, but there is no evidence in supplemental reports that contradicts the findings mentioned above. The preponderance of evidence standard has been met, and therefore the above allegations are found to be Substantiated. LPA is issuing a citation per California Code of Regulations, Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section Personal Rights. An exit interview was conducted, and appeal rights and a copy of this report were provided to Asst. Director La Tanya Harper, whose signature on this form confirms receipt. ... stated they drove into the youth to get the youth to move but later denied this. Based on LPA's review of video footage, R1 placed self on the hood and windshield of the vehicle and was directed by staff to get off of the vehicle. The vehicle appears to be stopped at this time. R1 removes self from the vehicle, and as R1 steps off and away from the vehicle, the vehicle is propelled forward about a foot at approximately 5- MPH. The speed is low but is high enough to indicate the gas was pressed rather than just the brake being lifted. R1's body is very close to the vehicle, and R1's hand is either still on the vehicle or had just been removed. From the driver's side, from where the video is shot, it is not clear that R1 would not be hit by the vehicle. However, R1 does not show signs of being hit. The vehicle's horn is then honked 6 times in succession. There is no apparent purpose for the honking other than perhaps to warn R1 from walking in front of the vehicle as it is now moving. Based on this footage, LPA determines that the staff operating the vehicle did not act appropriately, and their actions put the health and safety of R1 at risk. Individuals should not jump onto vehicles, and individuals should demonstrate extra caution when operating vehicles around others, especially if others are making attempts to place themselves on top of the vehicle. However, based on record review and confidential interviews, it is not clear that any of the injuries R1 sustained were caused by staff's actions rather than by R1's own actions. Although the allegation may have happened or is valid, based on LPA's observations and interviews with residents and staff, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. Therefore, the allegation is Unsubstantiated. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Asst. Director La Tanya Harper, whose signature on this form confirms receipt.

Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion: UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

report_type: Complaint Investigation

met_with: Asst. Director La Tanya Harper

complaint_status: unsubstantiated


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Based on record review and confidential interviews, S1 made a statement to R1 of a threatening nature that was a highly inappropriate thing to say to a child in care at a STRTP facility, as the statement could reasonably be interpreted by the youth as a threat. Police found the illegally concealed firearm (belonging to S2) during a search of the vehicle. Multiple charges were filed against S1 by police, including assault with a deadly weapon, criminal threats, and cruelty to a child. The charges were ultimately dropped, but there is no evidence in supplemental reports that contradicts the findings mentioned above. The preponderance of evidence standard has been met, and therefore the above allegation is found to be Substantiated. LPA is issuing a citation per California Code of Regulations, Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section Personal Rights. An exit interview was conducted, and appeal rights and a copy of this report were provided to Interim Administrator Nina Davis.

Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
Staff did not call the police immediately for each time the resident left due to the resident following a pattern of returning within 15 to 60 minutes. Additionally, the resident was a known risk for unauthorized leaves, which the facility expressed concerns with to the resident's authorized representative, but the facility found 1:1 supervision inaffective for the resident due to the resident becoming agitated by increased staff monitoring and being near staff, resulting in 1:1 supervision being terminated for the resident. The preponderance of evidence standard has been met, and therefore the above allegation is found to be substantiated. Due to the known risk for unauthorized leaves and not reporting the leave(s) immediately to the police, per facility protocol, LPA is issuing a citation of California Code of Regulations, Title 22, Section Plan of Operation. See attached LIC 9099-D. LPA also advises that per Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87065.5, the facility shall increase the number of direct care staff when a resident requires special care and supervision due to behavior. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Assistant Administrator La Tanya Harper, whose signature on this form confirms receipt. Additionally, the resident was a known risk for unauthorized leaves, which the facility expressed concerns with to the resident's authorized representative, but the facility found 1:1 supervision ineffective for the resident due to the resident becoming agitated by increased staff monitoring and being near staff, resulting in 1:1 supervision being terminated for the youth. There is not sufficient information to determine if a violation led to the incident occurring. Additionally, based on confidential interviews and record review, drug use is not allowed in the facility, and it has either not been witnessed by some parties or staff have been observed to confiscate contraband when they become aware of it. The facility is reported to have a menu residents enjoy, staff make quality meals and accommodate residents' dietary needs and preferences, residents are able to make their own meals if they prefer, and the facility was observed to have a large store of healthy food. However, at multiple visits, LPA observed food out of date or expired, including significantly moldy fruit that was exposed and accessible to residents. There is not sufficient information to prove that food service is overall inadequate. Further, based on confidential interviews, most residents report that staff do not bully and are not aggressive with residents. Staff use verbal intervention during altercations, but do not use physical intervention and are hands-off. Lastly, it was reported that medical documentation for a resident could not be located in order to provide to a paramedic who responded to the facility. The specific documentation could not be clarified, and LPA was able to have access to medical documentation. However, LPA advises that the facility ensure medical documentation is accessible to care staff in case of an emergency so that medical information can be provided to authorized parties. Although the allegation(s) may have happened or is/are valid, based on LPA's observations and interviews, there is not a preponderance of the evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegation(s) is/are unsubstantiated. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Assistant Administrator La Tanya Harper, whose signature on this form confirms receipt.

Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

met_with: Assistant Administrator La Tanya Harper


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

raw_content:
Narrative:
...school schedule. Per the facility's program statement, "Transportation is provided to all youth/NMDs to school unless the youth/NMD prefers to walk to school in which in that case it is right for their age, developmental level, maturity and it's in their Needs and Service Treatment Plan," which was not followed. Further, Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section Transportation provides that facilities shall ensure transportation is provided to residents with any special arrangements agreed upon with the care team and documented in the needs and services. Based on confidential interviews and record review, staff perform room searches with two staff and the resident(s) present during the search. This policy/procedure is not listed in the facility program statement. Additionally, based on confidential interviews, multiple reports indicated that staff have made inappropriate comments and spoken inappropriately of or with residents, including referring to resident as nasty for making a mess and discussing a resident and their personal matters around or with other residents. One of these staff is no longer employed by the licensee. Based on confidential interviews, staff did open a resident's expected mailed ID in order to make a copy of it and has done this before. However, it is not a policy or a trend that staff will open residents' mail, and no mail is withheld from residents. Staff do request that residents open packages in front of staff in order to log it on residents' inventory list and to ensure the item is not dangerous or contraband. Resident reports indicate this has not been an issue for residents. However, this is not listed in the facility program statement, and residents have a right to confidentiality in the mail they receive. Lastly, based on confidential interviews, a resident requested to be taken to the emergency room for pain, but staff did not agree to transport resident. Resident and a peer called 911, and when the ambulance arrived, staff spoke to the medics, who then left. Later that night, the resident again expressed their concern of their pain, and staff called the advice nurse, who advised the resident be taken to the emergency room, and the resident was transported by ambulance due to the late hour. The preponderance of evidence standard has been met, and therefore the above allegations are found to be substantiated. LPA is issuing citations of California Code of Regulations, Title 22, Sections Plan of Operation and Health Related Services and STRTP ILS Sections Transportation and Personal Rights. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Assistant Administrator La Tanya Harper, whose signature on this form confirms receipt. Based on confidential interviews, staff do provide transportation to the hospital, but if an incident occurs in the middle of the night, when the ratio only requires one staff on shift and on-call staff cannot arrive quickly enough, staff will allow a resident to be transported by ambulance. LPA advises that per Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87065. Direct Care Staff/Child Ratios, facilities with a capacity of 6 or fewer residents, when one or more residents are present, shall have at least one direct care staff on call and capable of arriving to the facility within 30 minutes. Based on confidential interviews and record review, a resident had a medical visit on 11/14/21, and the visit summary advised a follow-up appointment be made for one (1) week later, which would be around 11/21/21. Medical records reflect that multiple visits were made, but no visit summary for a visit around this time was observed. Based on interviews and record review, some appointments were cancelled or could not be scheduled within the physician's requested time frame, and some health appointments the resident elected to not go to. Resident records do not reflect a trend of not scheduling doctor appointments. There is insufficient information to determine that appointments are not made for residents. Although the allegation(s) may have happened or is/are valid, based on LPA's observations and interviews, there is not a preponderance of the evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegation(s) is/are unsubstantiated. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Assistant Director La Tanya Harper, whose signature on this form confirms receipt.

Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion: UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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:

Deficiencies:
87074: (3) Extracurricular, personal enrichment,...and social activities

met_with: Assistant Director La Tanya Harper

title: Transportation c) Unless other arrangements are specified in the Needs and Services Plan or the Transitional Independent Living Plan...a licensee shall ensure transportation is provided to...


raw_content:
Investigation Findings:
UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

met_with: Facility Manager Geramani Martin


investigation_findings: UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:


raw_content:
Investigation Findings:
13On 08/06/ Licensing Program Analyst (LPA), Celeste Aparicio made an unannounced inspection to the facility for the purpose of delivering findings from a complaint investigation. LPA met with Facility Manager and informed on the purpose of this visit. LPA reviewed documentation and conducted confidential interviews. After the review of documentation and interviews with relevant parties, it was found that the allegations could not be corroborated due to inconsistent statements and documentation obtained. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided to facility, whose signature on this form confirms receipt UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Celeste Aparicio LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Geramani Martin


raw_content:
Investigation Findings:
13On 3/7/25, Licensing Program Analysts (LPAs) Celeste Aparicio and Cole Oliver made an unannounced inspection to the facility for the purpose of delivering findings from a complaint investigation. LPA met with Geramani Martin, Administrator and informed Administrator on the purpose of this visit. LPA reviewed documentation and conducted confidential interviews. Through the investigation it was found that on 1/3/25, R1 and S2 got into a verbal argument regarding R2's confidential information. (See LIC811). The complaint alleged that during this verbal argument, staff did not treat youth with dignity. After the review of documentation and interviews with relevant parties, it was found that the allegation could not be corroborated due to insufficient evidence. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted, appeal rights were provided, and a copy of this report was left with Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Celeste Aparicio LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Administrator,Geramani Martin


summary: Facility Evaluation

raw_content:
Narrative:
On Tuesday, September 14, 2021 at 9:54AM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility for a required annual inspection. LPA met with Administrator Nina Davis and informed of the purpose of the visit. LPA used the Inspection Tool to complete the annual inspection. LPA toured the facility site and observed the facility to be clean and sanitary. Administrator informed LPA that the facility plans to get a new dusting rod to remove a hanging web/dust web in the entry way and to haul the old mattresses currently stored in the garage to the dump. Commonly touched services are sanitized regularly. Pool in backyard has a pool cover. Per Administrator, there are no firearms on the premises. Sharps and medications are stored in the locked closet in the entryway. First aid kit is stored centrally. Scissors and tweezers are missing from the first aid kit. Bedrooms are tidy, residents have individual beds, and beds have clean linens. The room temperature and hot water temperature measured within permitted ranges, at F and 114. F, respectively. The kitchen was in sanitary condition with functioning equipment and dishware, cookware, and utensils to meet the needs of residents in care. Food storage was sanitary, food was fresh and in date, and there was food storage to meet the 7-day nonperishable, 2-day perishable mandate. LPA reviewed all client files and staff files. Staff files were complete, and training record shows that the facility has been conducting trainings in 2021. Per Administrator, who is new in this position, the 2020 training record has not been found yet. 2019 training was complete for staff who were working at the facility that year. 1 file had a first aid certificate that was expired by just under a month, but the refresher training had been conducted, and the certificate needed to be placed in the file. 1 file for new hire was missing health screening, but the doctor visit to complete this was scheduled and evidence of the appt being scheduled was in file. [] Client files were mostly complete. See LIC Confidential Names for the following: - The file for R1 was missing or had incomplete: Identification/Emergency Info (LIC 601); Personal Rights (LIC 613B); Cash resources (LIC 405); and Physician's Report w/ TB Test (LIC 602). NOTE: R1 was placed a few days ago on 9/10/21. - The files for R2, R3, and R4 were missing: Personal Rights (LIC 613B). LPA issued 2 advisories per California Code of Regulations, Title 22, Section Health Related Services and STRTP Interim Licensing Standards Personal Rights. No citations were issued. An exit interview was conducted, appeal rights provided, and a copy of this report left with Administrator Nina Davis, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On Thursday 2/3/22 at 9:16AM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility to review training records, per the agreement established at the Noncompliance Conference on 9/23/21. The agreed upon terms were that the licensee would be subject to increased monitoring for at least 12 months and the licensee is to conduct monthly trainings on any of these topics: trauma-informed care practices, safe vehicle operation, proper de-escalation procedures when following residents in a vehicle, and firearm storage and safety. LPA met with Administrator Nina Davis and informed of the purpose of the visit. LPA also spoke to Assistant Director La Tanya Harper over the phone to discuss the report. Safety precautions were taken, including LPA wearing an N95 mask, hand hygiene and gloves, and screening call. LPA reviewed the training binder, training logs, and training certificates and obtained copies of the training logs. LPA observed the following: 1) Staff S1, S2, and S3 (See LIC Confidential Names) have not attended a training on firearms, per the logs. LPA advises that a make-up training be held for these staff members. 2) The AWOL Procedures training covered safe vehicle operation, based on the training materials previously provided to LPA, but the training log does not clearly reflect this, and the materials were not available in the binder due to being stored at the administrative office location. LPA advises that, since the requirement to have trainings on safe vehicle operation is in response to a staff member's unsafe operation of a vehicle during an AWOL incident, the materials be available for review at the facility site to verify for anyone reviewing the logs that it covered safe vehicle operation and/or that another all-staff training be conducted that specifically covers safe vehicle operation and is titled to reflect that. The training log is otherwise complete, and the licensee is in compliance. An exit interview was conducted with Administrator Nina Davis and Assistant Director La Tanya Harper over the phone. There are no citations. A copy of this report was provided to Administrator Nina Davis, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Britanee Windom conducted a case management inspection on 05/12/22 at 9: AM based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 6 out of Direct Care Staff and 1 out of 1 youth files were reviewed. 2 out of Direct Care Staff and 1 out of 1 youth were interviewed.(See the Confidential Names List, LIC 811, May 12, 2022). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, monthly 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 Windom observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Administrator Nina Davis.


summary: Facility Evaluation

raw_content:
Narrative:
On 9/16/22 at 3:55PM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility for a required annual inspection. LPA met with Administrator Nina Davis and Facility Manager Imani Richardson and informed of the purpose of the visit. The CARE Inspection Tool was used to conduct this inspection. Two staff interviews were conducted. No resident interviews were conducted due to resident being unavailable for interview. The facility was observed to be clean, sanitary, and tidy. There is food to meet the needs of resident in care, and the majority of food was within date. There is a pool with a locked cover. Medications and chemicals are stored where inaccessible to residents. A menu is posted in the kitchen. Facility license, facility sketch, emergency disaster plan, grievance procedures, and personal rights are all posted in the facility where visible to residents and visitors. COVID-19 symptoms, hygiene routines, and screening procedures are posted around the facility. Room temperature was maintained within permitted range, at F. Hot water at bathrooms measured 123. F, and all sinks had hot water caution signs posted. Despite the sign, the hot water still needs to be within the permitted range. LPA is issuing a citation of California Code of Regulations, Title 22, Section 80088. See attached LIC 809-D. LPA observed a bowl of fruit with a molded melon, which Facility Manager stated had been recently purchased. LPA observed that the bowl was placed on the kitchen table under the skylight. Facility Manager immediately threw out the fruit and cleared and cleaned the bowl. LPA advises that the facility ensure all spoiled food is thrown out promptly and advises that fruit be stored where it will remain fresh and out of direct sunlight. An annual continuation visit will be conducted to complete this inspection. An exit interview was conducted, appeal rights provided, and a copy of this report left with Facility Manager Imani Richardson, whose signature on this form confirms receipt.

met_with: Administrator Nina Davis, Facility Manager Imani Richardson


summary: Facility Evaluation

raw_content:
Narrative:
On 10/26/22, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility for an annual continuation. LPA met with Assistant Director La Tanya Harper and informed of the purpose of the visit. There are no residents in care, and the facility is temporarily not operating. Prior notice of this was provided to LPA. LPA used the CARE Inspection Tool to conduct this inspection. This continuation inspection was to complete the review of personnel files. Five files were reviewed, and the following deficiency was observed. Staff S1 (See LIC Confidential Names, dated 10/26/22) did not receive 40 hours of annual training. From 8/2021 to 8/2022, S1 received 25 hours of training, per the training documentation and certificates available for review. LPA is issuing a citation of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87065.1. See attached LIC-809-D. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Assistant Director La Tanya Harper, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 10/26/22 at 12PM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility to review training records, per the agreement established at the Noncompliance Conference on 9/23/21. The agreed upon terms were that the licensee would be subject to increased monitoring for at least 12 months and the licensee is to conduct training on any of these topics: trauma-informed care practices, safe vehicle operation, proper de-escalation procedures, and firearm storage and safety. LPA met with Assistant Director La Tanya Harper and informed of the purpose of the visit. LPA reviewed the training binder, training logs, and training certificates and observed that all staff have received the required trainings. One staff, S1 (See LIC Confidential Names, dated 10/26/22), has not completed 40 hours of annual training, completing only 25 hours between the period of 8/2021 to 8/2022. The facility was cited for this under the LIC Annual Inspection, dated 10/26/22, so another citation is not being issued under this report. LPA discussed the deficiency with Asst. Director and developed a plan of correction under the annual report. No additional deficiencies were observed during this inspection. An exit interview was conducted, and a copy of this report left with Asst. Director La Tanya Harper, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Alyssa Ng on 2/10/23 at 11AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Ng met with Nina Davis, Administrator and inspected the facility inside and out. LPA reviewed 0 of child's records and 3 of staff personnel files on site at the facility. LPA reviewed 0 of child's psychotropic medications and medication records. LPA interviewed 3 of staff on site to discuss the facilities policies and procedures of operation. LPA interviewed 0 of children currently prescribed psychotropic medication. LPA provided a copy of this licensing report to Nina Davis, Administrator. No deficiencies are being cited at this time. LPA conducted exit interview with Nina Davis, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On 3/10/23 at 3:25PM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility to review training records, per the agreement established at the Noncompliance Conference on 9/23/21. The agreed upon terms were that the licensee would be subject to increased monitoring, and the licensee is to conduct training on any of these topics: trauma-informed care practices, safe vehicle operation, proper de-escalation procedures, and firearm storage and safety. LPA met with Facility Manager Danielle Rosenbaum and informed of the purpose of the visit. LPA reviewed the training binder, training logs, and training certificates and observed that all staff have received the required trainings. LPA reviewed the training hours for facility managers, and all have received facility manager training and have over 40 hours of training for the annual period. There is one resident in care who is still at school. LPA interviewed two staff. There were no deficiencies observed at this visit. An exit interview was conducted, and a copy of this report left with Facility Manager Danielle Rosenbaum, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 6/23/23, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility to conduct an inspection, per the agreement established at the Noncompliance Conference on 9/23/21. The agreed upon terms were that the licensee would be subject to increased monitoring, and the licensee is to conduct training on any of these topics: trauma-informed care practices, safe vehicle operation, proper de-escalation procedures, and firearm storage and safety. LPA met with Facility Manager Geramani Martin and informed of the purpose of the visit. LPA reviewed staff records and resident records. LPA observed complete files and complete training records. Staff have been trained on required topics and the hours are clearly documented. LPA conducted 1 confidential interview, but additional review is required in order to complete this inspection. LPA collected staff contact information in order to interview on a later date. An exit interview was conducted, and a copy of this report was provided to Facility Manager Geramani Martin, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 9/26/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a required annual inspection. LPA met with Facility Manager Geramani Martin and informed of the purpose of the visit. LPA toured the facility site and grounds and inspected facility records. Two residents could not be interviewed due to being on runaway status or declining an interview. No serious deficiencies were observed. Using the CARE Inspection Tool, LPA did observe that one resident's file (R1 - See LIC Confidential Names) was missing a signed medical consent form. The resident was admitted this month, so LPA is issuing an advisory. See LIC 9102. LPA obtained a current LIC 500 and LIC 610. An exit interview was conducted, appeal rights discussed, and a copy of this report was left with Facility Manager Geramani Martin, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 10/19/23, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility to conduct the facility's final quarterly inspection, per the agreement established at the Noncompliance Conference. LPA met with Administrator Maurice Jones and informed of the purpose of the visit. The agreed upon terms were that the licensee would be subject to increased monitoring, and the licensee is to conduct training on any of these topics: trauma-informed care practices, safe vehicle operation, proper de-escalation procedures, and firearm storage and safety. LPA reviewed staff training records and confidential interview. LPA observed complete training records reflecting the required hours being met and the required topics being covered, including trauma-informed care practices and verbal intervention/de-escalation. Based on LPA's observations, record review, and confidential interviews, the facility was observed to be operating in compliance with applicable regulations/licensing standards and the NCC terms. No deficiences were observed during today's visit, and there are no outstanding plans of correction (POCs). An exit interview was conducted, and a copy of this report was provided to Administrator Maurice Jones, whose signature on this form confirms receipt.

met_with: Administrator Maurice Jones


summary: Facility Evaluation

raw_content:
Narrative:
On 3/20/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit to follow-up on a reported incident. LPA met with Administrator Maurice Jones and informed of the purpose of the visit. The incident in question is one where a resident gained access to a knife from locked storage during an escalated event. LPA conducted confidential interviews with involved resident and Administrator. LPA obtained contact information for other involved parties. Further investigation is needed. There is no evidence of deficiency at this time. An exit interview was conducted, appeal rights discussed, and a copy of this report was left with Administrator Maurice Jones, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 3/27/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit at the facility. LPA met with Facility Manager Geramani Martin and informed of the purpose of the visit. The purpose of the visit was to follow-up on an incident report and on LPA's previous visit for this incident, conducted on 3/20/24. At the previous visit, LPA obtained contact information for other involved party(ies). Based on LPA's confidential observations, interviews, and record review, LPA determined that staff appropriately de-escalated an altercation during which a resident pushed staff out of the way in order to obtain a knife. Knives were previously stored in the locked staff closet with client records. During the incident, staff needed access to the client records to provide information to emergency personnel who had been called during the incident to help support. The facility has moved knives to another location that is even less accessible to residents in care. An exit interview was conducted, appeal rights discussed, and a copy of this report was left with Facility Manager Geramani Martin, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/23/24, Licensing Program Analyst (LPA) Celeste Aparicio made an announced collateral visit to the facility to conduct a confidential interview. LPA met with Direct Care Staff, and informed Direct Care Staff on the purpose of the visit. LPA conducted one confidential interview related to an outside investigation. An exit interview was conducted, and a copy of this report was left with Direct Care Staff whose signature on this form confirms receipt.

met_with: Direct Care Staff, Jasmine Rutledge


summary: Facility Evaluation

raw_content:
Narrative:
On 2/20/25, Licensing Program Analysts (LPAs) Celeste Aparicio and Omar Sawyer made an announced collateral visit to the facility to conduct a confidential interview. LPA met with Jazmine Rutledge, Facility Manager and informed Facility Manager on the purpose of the visit. LPAs conducted one client confidential interview related to an outside investigation. An exit interview was conducted, and a copy of this report was left with, Facility Manager whose signature on this form confirms receipt.

met_with: Jazmine Rutledge,Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 06/10/25, Licensing Program Analyst (LPAs) Celeste Aparicio and Cole Oliver conducted a random annual inspection. LPAs met with Facility Administrator, Geramani Martin and informed the Administrator on the purpose of the visit. LPA's toured the facility site inside and out, reviewed two client files, three staff files, and conducted one confidential interview. During the inspection one client was present. The CARE Inspection Tool was used to conduct the inspection. The facility is a two-story house in a residential neighborhood and has 4 single-occupancy bedrooms and one client shared bathroom. The facility and grounds are clean, tidy, and free of obstructions. LPAs observed the facility to be maintained at 72 degrees and hot water temperature measured within the appropriate range. LPAs observed food supply to be sufficient, and the appropriate forms to be posted around the facility. Chemicals were stored and locked up in the garage. LPAs identified two areas in which technical assistances are beneficial. LPAs are issuing technical assistance for California Code of Regulation (CCR) section 80069(a)(1),and Interim Licensing Standards (ILS) 87088(c)(2). An exit interview was conducted and a copy of this report was provided to Administrator, whose signature on this form confirms receipt.

met_with: ADMINISTRATOR, GERAMANI MARTIN


summary: Facility Evaluation

raw_content:
Narrative:
On 6/30/22 at 2:55PM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility to review training records, per the agreement established at the Noncompliance Conference on 9/23/21. The agreed upon terms were that the licensee would be subject to increased monitoring for at least 12 months and the licensee is to conduct monthly training on any of these topics: trauma-informed care practices, safe vehicle operation, proper de-escalation procedures when following residents in a vehicle, and firearm storage and safety. LPA met with Direct Care Staff Keisha Ward and Direct Care Counselor Imani Richardson and informed of the purpose of the visit. Pre-visit contact was made in the morning of the day of visit. LPA reviewed the training binder, training logs, and training certificates and obtained copies/scans of the training logs. LPA observed the following: 1) At the last visit, on 2/3/22, it was observed that not all staff had attended a training on firearm safety. At today's visit, it was observed that the staff missing the training have since attended. 2) All except for one staff have been trained on safe operation of vehicles. 3) The facility is conducting trainings on listed, and related, topics about every 30 days / monthly, per the agreement. However, per the training logs, not all staff have attended trainings. Two staff training logs do not reflect any trainings have been completed since 3/29/22, and one staff training log does not reflect any training since 3/9/22. Staff logs reflect that staff have completed as much as 20 hours and as little as 8 hours of training in the past 12 months and do not reflect that the 40hr requirement has been met. 4) Lastly, LPA observed that staff on site, who is the only staff present while two residents are present, is not trained to the level of a facility manager. The 4PM shift's staff were also not facility managers. LPA is issuing two citations, per Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section Personnel Requirements and Section 87065. Supervision, Evaluation and Training Requirements. An exit interview was conducted, appeal rights provided, and a copy of this report left with Direct Care Counselor Imani Richardson, whose signature on this form confirms receipt.

met_with: Care Staff Keisha Ward


facility_name: LIGHTHOUSE MENTORING CENTER 4

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

raw_content:
Narrative:
The needs and services plan dated 10/21/21 includes the following: "Transition Plan: [R1]'s current plan is to graduate high school and move back with her grandmother or transition to a county connected independent living program. The staff and counselors at Lighthouse Mentoring Center are supporting [R1]'s connection with her grandmother and guiding and educating her on the resources available through the Independent Living Program. Additionally, [R1] is working on developing other independent living skills, such as securing, and retaining employment, budgeting and managing her own transportation." The complaint report was filed on 10/20/21 in response to an incident that day. The transition plan was updated after the incident. Administrator informed LPA that the plan was not updated before because the plan to manage own transportation had been verbally discussed and agreed upon at a CFT. This was, though, before R1 changed schools. Additionally, the facility did not have a record of bus routes that R1 was to utilize to make their way home, and Administrator was unaware of what bus route R1 would need to take to get home to the facility, which is a safety concern. Based on LPA's review of local bus routes, the 9-minute car ride home would have taken R1 an average of 2 hours to get home by bus. The only route that would be quicker (but still 90 minutes) costs more than the amount of money R1 is provided to self-transport. Multiple routes require multiple transfers, and R1 is a known AWOL risk, per interview and record review. Staff are able to transport youth to work after school on days R1 works, but the facility does not have a schedule for R1's job, because the employer does not provide these to R1. However, staff availability indicates that staff are available to pick up the youth after school. Further, the route home from R1's previous school was about 37 to 44 minutes by bus. The preponderance of evidence standard has been met, and therefore the above allegation is found to be Substantiated. There is one citation. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Tracy McWoodson, whose signature on this form confirms receipt.

Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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

Deficiencies:
87074: ...(2) School... (3)	Extracurricular, enrichment...

met_with: Administrator Tracy McWoodson

title: Transportation  (c) Unless other arrangements are specified in the Needs and Services Plan or the Transitional Independent Living Plan..., a licensee shall ensure transportation is provided to the following


raw_content:
Narrative:
Residents upstairs call for staff, both of whom are downstairs. S1, who was upstairs with the residents, had gone downstairs prior to the incident to use the restroom. S1 reported that S2 was made aware of this and was nearby downstairs with another resident but may not have been able to see the residents upstairs. S2 reported that S2 was not made aware that S1 was using the restroom and that S2 was in the kitchen area with the fifth resident in care. S2 responded when called by the residents. The lighter, and per staff statements, multiple lighters on multiple occasions, were confiscated from R3. However, due to lack of supervision, the lighter could not be confiscated at the time of the incident, the incident of R3 using a dangerous item could not be prevented or intervened, and R3's injury could not be prevented. Further, resident and staff statements indicate that staff interactions with youth are not always trauma-informed and that multiple staff members at times use an inappropriate and disrespectful tone with residents when delivering information or explaining consequences. When staff share information with residents, the tone, word choice, and body language are important in delivery of that information. Additionally, if a resident responds negatively to a staff statement, staff are responsible for ensuring they use trauma-informed care, per policy procedures, to calm the resident, communicate their intentions, and to maintain the relationship between staff and residents and the health and safety of the resident. Staff tone and attitude contribute significantly to the environment in the facility. The preponderance of evidence standard has been met, and therefore the above allegation(s) is/are found to be Substantiated. LPA is issuing a citation of California Code of Regulations, Title 22, Division 6, Chapter 1, Article 7, Section 80087(g) Buildings and Grounds and Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87065.2(b)(1) Personnel Duties and Section 87072(c) Personal Rights. An exit interview was conducted, appeal rights provided, and a copy of this report left with Administrator Tracy McWoodson, whose signature on this form confirms receipt.

Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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

Deficiencies:
87065.2: (1) Supervision, protection, and care of children at all times, individually and in groups.

met_with: Administrator Tracy McWoodson, Clinical Director Phyllis Ritter

title:
Personnel Duties
(b) Direct care staff shall perform the following duties


raw_content:
Narrative:
S1 did not engage with R1 as part of planned ignoring and did not realize that P1 was overhearing R1's statements. By staff taking a personal call while at the facility, confidential information and/or identifying information such as names, voices, and private conversations of residents can be heard by individuals not affiliated with the facility or youths' care teams, which is a privacy and personal rights risk. Immediately prior to the incident, S1 had gone to use to the downstairs bathroom, and S2 was downstairs, and staff were not able to prevent P1 from entering the facility and going upstairs. The front door, which is typically locked, per staff, was unlocked. P1 went upstairs trying to identify who it was who was disrespectful to S1 earlier. R1 was in another resident's room, which is the door nearest the top of the stairs. P1 entered, and the altercation began. The preponderance of evidence standard has been met, and therefore the above allegation(s) is/are found to be Substantiated. LPA is issuing a citation of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87065.2(a)(2) Personnel Duties and Section 87072(c)(10) Personal Rights. An exit interview was conducted, appeal rights provided, and a copy of this report left with Administrator Tracy McWoodson, whose signature on this form confirms receipt.

Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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

Deficiencies:
87065.2: (2) Supervising the direct care staff, ensuring appropriate care and supervision is provided to children in accordance with applicable law, licensing regulations, and the facility's policies

title: Personnel Duties  (a) The facility manager(s) shall...be responsible for


raw_content:
Narrative:
Although the allegation may have happened or is valid, based on observations and interviews with residents and staff, there is not a preponderance of the evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegation is Unsubstantiated. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Tracy McWoodson, whose signature on this form confirms receipt.

Investigation Findings:
UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Additionally, based on record review, a resident was alleged to have been denied medication, but records reflect prescribed medications were administered and logged. Based on confidential interviews, the allegation may have no reasonable basis. However, during record review, LPA observed that some medications were not administered for a few days due to needing to be filled, and one medication was potentially administered incorrectly or logged incorrectly. A medication, Aripiprazole, was prescribed at 1 1/2 tablets at bedtime for 15 days and filled on 2/18/22 with 1 refill, administered for 15 days, and then filled on 3/18/22 with 0 refills. The facility continued administering daily until they ran out after 4/10/22. If the medication was only to be administered for 15 days, administration should have stopped after 4/1/22, and at 1 1/2 (1+1/2) dosage, the facility would be out of the medication after 4/1/22. However, after filling the 3/18/22 prescription, the records reflect that staff notated the medication was not administered due to needing to be filled. The resident is no longer in care, so a medication count cannot be conducted. Although the allegation(s) may have happened or is/are valid, based on LPA's observations and interviews, there is not a preponderance of the evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegation(s) is/are unsubstantiated. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Tracy McWoodson, whose signature confirms receipt.

Investigation Findings:
UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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


raw_content:
Narrative:
allegations, one confirmed, and two were unable to determine. Based on record review, clients were threatened by other minors. The facility staff coordinated with other facility staff and the attending school to mitigate physical violence. LPA was not able to interview the client involved because they were on an extended unauthorized absence from the facility, then declined to interview. The client is now reunified with a relative. Although the allegations that facility does not provide a safe environment for minor, facility staff are verbally abusive to minor, and other minors fight and threaten minor may have happened or is/are valid, based on LPA's observations and interviews, there is not a preponderance of the evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegations are unsubstantiated. LPA conducted an exit interview with Danielle Rosenbaum, Facility Manager, whose signature confirms the receipt of this document.

Investigation Findings:
13On 10/24/2022 at 11:20AM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the facility. The purpose of this visit is to inform the facility of the findings on the listed allegations. LPA met with Danielle Rosenbaum, Facility Manager. During the course of the investigation, LPA Hood conducted six confidential interviews. LPA reviewed the client Needs and Services Plan, incident reports, and an Investigations Branch (IB) investigation done into different allegations regarding the same youth. LPA reviewed the CWS investigation regarding this incident, CPS did not conduct an investigation because it did not meet child endangerment criteria. Based on record review and interviews, the facility provided a safe environment for minor and followed facility protocol when dealing with external threats. Based on interviews, there is conflicting information whether staff are verbally abusive to minors in care. Of the six interviews, three interviewees denied these UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Selena Hood 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 14-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, FACILITY NAME: LIGHTHOUSE MENTORING CENTER 4FACILITY NUMBER: VISIT DATE: 10/24/2022

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

met_with: Danielle Rosenbaum


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
The resident previously self-transported via public transportation with staff transporting to the local BART station. However, following an incident that caused a safety concern for the resident, the care team agreed to have staff transport the resident. The facility and care team have developed and implemented a plan to gradually transition the resident back to self-transport via BART. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Tracy McWoodson, whose signature on this form confirms receipt.

Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion: