summary: Facility Evaluation

raw_content:
Narrative:
On 06/12/2024 at 10: AM Licensing Program Analyst (LPA) Mona Lam and LPA Mariah Hawkins conducted an unannounced case management inspection. LPA Lam and LPA Hawkins met with Licensee, Audra Stance. The purpose of the inspection was to gather additional information regarding an update on an incident report dated 5/25/24. During the inspection, LPAs interviewed Licensee. Licensee discussed with LPAs that a follow-up was conducted with participant C1 (refer to LIC 811, dated 6/12/24 for confidential names). Licensee conducted an unannounced inspection at the living unit and observed no dangerous items or safety concerns. Licensee also interviewed involved participant and roommate, and both reported no dangerous items or safety concerns. Due to no evidence of dangerous items or safety concerns, the Licensee determined there was no further action needed. LPAs discussed follow-up procedures with Licensee and advised documenting on-site living unit inspections and participant interviews, and maintaining documentation at the facility site. In addition, LPAs advised communicating safety concerns to social worker. An exit interview was conducted and no deficiencies cited during today's inspection. A copy of the report was left with the Licensee.

met_with: Licensee, Audra Stance


state: CA

facility_name: B.W.I.T. LUXURIOUS FOSTERING

summary: Facility Evaluation

raw_content:
Narrative:
On 11/19/2024 at 4:00PM, an informal virtual meeting was conducted with Audra Stance regarding increase of capacity to 50 and compliance history since facility was licensed on May 17, 2024. The following were present at the meeting: Helga Wong - Regional Manager Isabel Diego- Licensing Program Manager Carolyn Flynn- Licensing Program Manager Audra Stance- BIWT Administrator During the meeting, Community Care Licensing (CCL) discussed with BWIT Administrator the review of the increase of capacity request to 50 capacity that will be on hold; facility compliance history of deficiencies on withholding allowance, cash resources records, personal rights, reporting requirements, living unit certification and discharge of client; legal review; age exceptions. BWIT Administrator explained the reason on increase capacity due to additional referrals from the County and discussion of the youths in care. CCL provided information on THPP regulation for minor in care and Trauma Informal, Plan of Operation, and offered Technical Assistance Meeting to assist the THPP program.

report_type: Facility Evaluation

met_with: Audra Stance


summary: Facility Evaluation

raw_content:
Narrative:
On 06/04/2025, Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced annual inspection and met with Wesley Sheppard, Lead Case Manager. Director Audra Stance is currently out of town and authorized Wesley Sheppard to facilitate the inspection via phone. LPA Medina confirmed that the Designation of Facility Responsibility form was completed prior to Director Stance's departure. Upon arrival, no staff were present in the office. Staff arrived at approximately 11: AM. The Transitional Housing Placement Plus Foster Care (THP+FC) program serves non-minor dependents. During the inspection, LPA received an updated copy of the LIC Personnel Report to ensure the facility's records remain current. An updated list of participant residential units was also obtained. A review of the Guardian background check system on June 4, 2025, confirmed that all staff associated with the program had cleared Department of Justice (DOJ), Federal Bureau of Investigation (FBI), and Child Abuse Central Index (CACI) background checks. Using the CARE Inspection Tool, LPA conducted a walkthrough of the office at 11: AM. The office has sufficient space for confidential meetings, and the agency's license was observed to be prominently posted. LPA also observed a designated room for client relaxation. No deficiencies were noted during this portion of the inspection. Continues on LIC809-C At approximately 12: PM, LPA reviewed five client files. The facility representative was unable to provide Needs and Services Plans or equivalent documentation for four out of the five client files reviewed. Admission agreements, consent forms, emergency contacts, personal property/valuables lists, and signed personal rights acknowledgements were present. An area for improvement observed by LPA Medina was the organization of clients' cash resource records. Currently, all records are combined into one folder, rather than being individualized per client for Licensing review. One deficiency and one technical advisory were identified in this section. Please refer to LIC809-D and LIC9102 for further details. At 2: PM, LPA reviewed five staff files. No deficiencies were identified using the CARE Inspection Tool. LPA Medina observed current first aid certifications, fingerprint clearances, educational verification, personnel records, health screenings, criminal record statements, employee rights documentation, and completed TB tests. An area for improvement was noted regarding the LIC Personnel Records: not all forms included the employee's date of hire. Please refer to LIC9102 for details. At 3: PM, LPA reviewed the Operations section of the CARE Inspection Tool. LPA verified that all residential units had valid Certificates of Compliance. The facility representative also provided an updated client roster. No deficiencies were observed in this section. At 3: PM, LPA reviewed the facility's disaster preparedness plan. The review included the LIC610C, and LPA confirmed that all staff have assigned roles in the event of an emergency. However, the facility was unable to provide documentation of emergency drills upon request. One deficiency was observed in this section. Please refer to LIC809-D. This annual inspection is now complete. As a result of the inspection, one Health and Safety Code violation was cited under section 1565(c), and one violation was cited under Interim Licensing Standards (ILS) section 86270(a)(2)(C). Two areas of improvement were identified. Please refer to LIC 9102 for further details. An exit interview was conducted, appeal rights were provided, and a copy of this report was left with Lead Case Manager Wesley Sheppard, whose signature on this form confirms receipt.

visit_type: Annual

met_with: Wesley Sheppard - Lead Case Manager


summary: Facility Evaluation

raw_content:
Narrative:
Summary: An online, informal meeting was held on August 1st, 2025 at 9am on Microsoft Teams. The purpose of this meeting was to discuss concerns observed by the department and a proposed capacity increase. Attendance: Community Cares Licensing Representatives Regional Manager: Helga Wong Licensing Program Managers (LPM): Joel Segura Licensing Program Analyst (LPA): Jonathan Medina, Will Ea Facility Representatives Administrator: Audra Stance Compliance Manager: "Ms. J" Jammesie Jones Program Facilitator: Vissana Khouvicith Lead Case Manager: Wesley Shepperd Agenda: The following are topics that were discussed based on concerns the department observed during past inspections and relating to proposed changes: (Page 1 of 4) (Page 2 of 4) Agenda 1: Past Citations/Issues Personal Rights: Facility was cited for multiple violations of personal rights stemming from violations of (1) maintaining the privacy of clients' medical information, (2) treating clients in a respectful manner/inappropriate comments to clients in care, (3) using availability of shelter as a punitive measure (4) not according residents with the right to file complaints free of punishment Cash Resources Management: Facility was cited for not ensuring that cash resources were properly returned to client upon their discharge from the facility Record Keeping: On April 5th, 2024, the facility was cited for a number of issues related to proper record keeping, including (1) maintaining an up-to-date list of current residents (2) providing notice to CCLD concerning census changes (3) reporting to CCLD within 7 days of any incident in which a residents' safety is at risk (4) reporting to CCLD within 10 days on any changes to the facility plan of operation. During a recent annual inspection, a citation was given for not (5) maintaining a Needs and Service plan for all clients within the facility's care. Agenda 2: Capacity Increase Facility shared presentation on positive changes and services BWIT now offers Capacity Increase Goal: What is the target number of the proposed capacity increase and what is the goal of the increase? Facility Response: Increase capacity from 30 to 50. Capacity Increase Plan: What are some of the preparations needed to accommodate the increased capacity? (staffing considerations) Facility Response: Established relationship w/ non-profit to source furniture, both used and new Developed trauma informed care training. () (Page 3 of 4) Facility Response (continued): Establish High Standard of Care Fully furnished housing Always provide brand new beds Single housing unit for each client Two bedroom units with clients that have children Pet friendly. Parenting youth receive additional stipend. Social Events to create memories and build community (BWIT Prom) Mentorship programs. How to apply for college. driven by individual goals of clients Currently have 5 case managers Agenda 3: Available Support Resources Technical Support Program: Shared information about TSP, a non-enforcement, voluntary service offered to support Providers to meet regulatory compliance. TSP offers 1:1 support in the form of consultation, trainings, and resources for a variety of Community Care Licensing (CCL) topics to all facility types. Agenda 4: Acknowledgement of Progress Initially struggled due to lack of experience. Since first informal meeting 10 months ago, took advice to heart and built a team to support one another Has 90% success rate with a challenging client population Every client that has come through the program has obtained their high school diploma Weekly Checkins w/ Clients Mental health Physical health Property check/maintenance Check progress on short-term and long-term goals Case Manager is required to document visitation notes () (page 4 of 4) Agenda 4: Acknowledgement of Progress (continued) Weekly Check In (continued) CCLD: Encourage transparency and communication with your LPAs/LPMs CCLD: Encouraged to celebrate successes/accomplishments with clients Hold events to socialize and create memories/community for clients (BWIT Prom) Establishment of mentorship program help learn life skills learn how to set and accomplish whatever goals they have Created "BWIT Moving w/ Purpose" moving service, to transition into or out of the program Fully insured moving service Assistance w/ packing and supplies Short/long distance Van used to shuttle residents to any events/appointments clients have outside of moves Agenda 5: Closing/Follow Ups During this meeting a plan for compliance was discussed, TSP services were discussed and offered to the program, specifically for help with maintaining needs and services plans and training on personal rights. The facility expressed their interest in consulting with TSP. The meeting was concluded. Follow Up Items Facility: Update Program Statement/Plan of Operation w/ all of the program additions shared w/ CCLD today. Provide to LPA Will Ea Facility: Provide updated LIC 500 with new staff hirings to LPA Will Ea Facility: Provide updated LIC Monthly Operating Statement reflecting increased costs/balances as a result of capacity increase to LPA Will Ea CCLD: LPA Will Ea will pass along information regarding how to engage w/ TSP team

met_with: Audra Stance, Facility Admin


summary: Facility Evaluation

raw_content:
Narrative:
On 4/5/24, Licensing Program Analyst (LPA) Mariah Hawkins and Licensing Program Manager (LPM) Isabel Diego conducted a case management visit to address deficiencies found during an investigation at the facility. LPA and LPM met with Director Audra Stance and informed of the purpose of the visit. Based on confidential observations, interviews, and record review, the following deficiencies were found. Staff spoke about residents' personal matters, including a resident's private health matter, with other resident(s) and therefore did not ensure confidentiality. LPA is issuing a citation of Transitional Housing Placement Program Nonminor Dependent (AB12) Interim Licensing Standards (ILS) Section Personal Rights, Subsection (a)(12). Staff arrived to a residential unit in the middle of the night and banged on a resident's bedroom door to wake them up due to them not responding to the staff member earlier in the day. Additionally, a staff member told a resident that they were blocking the resident from contacting their phone number. LPA is issuing a citation of ILS Section Personal Rights, Subsection (a)(11). The facility became aware of residents engaging in dangerous behaviors such as illegal sex work and threats of violence toward another resident. Further, written correspondence reflects social worker(s) may not have been notified of ongoing behavior incidents and issues leading up to a termination from the program in a timely manner. LPA is issuing a citation of ILS Section Reporting Requirements, Subsection (c). See Page PAGE Additionally, the facility did not follow the approved plan of operation (POO) dated 04/12/2023. The facility fined two residents for property damage caused by a physical altercation that resulted in damage to an interior door and a mirror. The residents were required to split the cost of the repair. The POO indicates a damage deposit of $500 is to be set aside for each resident, from which the cost of damages will be deducted, and an itemized damage report is to be completed. This was not followed. Additionally, the facility sent a notice to residents via text of various policy changes, including putting leases and bills in the residents' names and changing program incentives, and did not report the changes to the Department until instructed by the Department to do so. LPA is issuing a citation of ILS Section Reporting Requirements, Subsection (d). Lastly, during today's visit, LPA observed that certificate of compliances were only available for one of four residential sites in use, and two remote residential sites were approved for use without notification made to the Licensing agency. LPA is issuing citations of California Code of Regulations, Title 22, Chapter 7, Section 86030. Identification of Transitional Housing Placement Program Participant Living Units, Subsection (a) and Section 86031. Notification, Subsection (b). Furthermore, LPA and LPM provided technical assistance with applicable requirements, including reportable incidents, law enforcement contacts, certificate of compliances. See attached LIC 809-D pages. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Director Audra Stance.

visit_type: Case Management

met_with: Director Audra Stance


facility_name: CALIFORNIA IMPACT COALITION FOUNDATION

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Monica Pavia made an announced prelicensing inspection, on above date. LPA met with applicant, Rupinder Dhillon and Mandave Sandhu, and toured the office suite. The applicant is applying for a Transitional Housing Placement plus Nonminor Dependents (THP+NMD) license. Files will be kept locked in a filing cabinet in the back office, on site. If needed, confidential meetings can be held at the THP+NMD office with a locked door. All staff hired for this license will be fingerprint cleared prior to working with participants. LPA discussed records required for staff and participants. This application has been reviewed by LPA Pavia and will be ready for licensure once the Licensing Program Manager (LPM), has reviewed and approved the application. LPA will notify you of licensure date and email facility license.

visit_type: Prelicensing

met_with: Rupinder Dhillon


summary: Facility Evaluation

raw_content:
Narrative:
Visit was attempted on 12/20/24 at AM. LPA will return at a later date to conduct Post Licensing. See LIC 812 pertaining to attempted visit.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On July 8, 2025, Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced Post Licensing Inspection and met with Mandave Sandhu, Lead Case Manager. Due to a prior unsuccessful attempt to finalize a visit, this inspection is labeled as an "Annual" in FAS; however, it is officially the facility's Post Licensing inspection. As the facility failed to accommodate two previous inspection attempts, a deficiency is being cited under Title 22, Section 80044(c) - Inspection Authority of the Licensing Agency. Please refer to LIC 809-D for further information. Staff began arriving at the facility at approximately 11: AM. The Transitional Housing Placement Plus Foster Care (THP+FC) program serves non-minor dependents. During the inspection, LPA obtained an updated LIC 500 (Personnel Report) to ensure the facility's records are current. An updated list of participant residential units was also collected. A review of the Guardian background check system on July 8, 2025, confirmed that all staff associated with the program had cleared Department of Justice (DOJ), Federal Bureau of Investigation (FBI), and Child Abuse Central Index (CACI) background checks. However, one staff member-John "Nick" Moriana, the facility's Administrator-was not associated with the facility in Guardian. LPA reminded the facility that all staff working for CA Impact Coalition must be associated with the facility in Guardian. The Administrator was successfully associated by the end of the visit. At 11: AM, LPA conducted a walkthrough of the administrative office using the CARE Inspection Tool. The office has sufficient space for confidential meetings, and the agency's license was prominently posted. LPA also observed a designated room intended for client relaxation. Client and staff files were stored in a secure room with locked cabinets. No deficiencies were observed during this portion of the inspection. At approximately 12: PM, LPA reviewed five client files. The facility was able to provide Needs and Services Plans for all five clients selected at random. However, the plans were missing signatures from the authorized placing agency representative. The facility sent the plans to the assigned social workers during the inspection, and the signatures were obtained before the conclusion of the visit. A technical violation was issued. Please refer to LIC 9102 for additional details. Admission agreements, consent forms, emergency contact information, personal property/valuables lists, and signed personal rights acknowledgments were present in all reviewed files. At 1: PM, LPA reviewed two of the three staff files listed on the facility's LIC 500. The three identified staff included the Licensee, Administrator, and one Case Manager. However, there was no personnel file available for the Licensee. A deficiency was cited under Title 22, Section 80066(a) - Personnel Records. While the facility attempted to gather the necessary documentation during the visit, the Licensee's file was not available upon request. Other staff files contained the required documentation, including current First Aid/CPR certifications, fingerprint clearances, educational verification, TB test results, criminal record statements, health screenings, personnel records, and employee rights forms. Please refer to LIC 809-D for further information. At 2: PM, LPA reviewed the Operations section of the CARE Tool. All residential units had valid Certificates of Compliance, and an updated client roster was provided. No deficiencies were observed in this area. At 2: PM, LPA reviewed the facility's disaster preparedness documentation, including the LIC 610C. LPA verified that all staff had assigned roles in the event of an emergency. However, the facility was unable to provide documentation confirming that emergency drills had been conducted. A technical assistance was given in this area to start keeping this record in binder. Please refer to LIC9102 for details. This Post Licensing Inspection is now complete. As a result, the facility was cited for two violations: one under Section 80066(a) - Personnel Records, and one under Section 80044(c) - Inspection Authority of the Licensing Agency. In addition, two technical violations/assistances were noted: one for missing authorized representative signatures on Needs and Services Plans, and one for the lack of documentation for emergency drills. Please refer to LIC 9102 for more details. An exit interview was conducted, appeal rights were provided, and a copy of this report was left with Lead Case Manager Mandave Sandhu, whose signature confirms receipt.

Deficiencies:
80066(a): The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.  Each personnel record shall contain the following information

met_with: Mandave Sandhu - Lead Case Manager


summary: Facility Evaluation

raw_content:
Narrative:
Control Number - 2454-FN - FN On December 16, 2025, at 2: PM, Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced case management inspection at the above-referenced facility to follow up on a submitted Incident Report (IR). LPA met with Antonio Pizano, Resource Coordinator. Mandave Sandhu, Lead Case Manager, was also present during the visit. During the inspection, LPA interviewed staff regarding an incident that occurred on November 25, 2025. According to the report, two clients were relocated after being asked to leave a temporary Airbnb shelter due to noise complaints. As a result of this incident, the program is no longer permitted to use Airbnb. Staff interviews revealed that one of the clients had been relocated four separate times. This incident is connected to a previous event in which the client's original unit was damaged in a fire. After leaving the first Airbnb location, the client was moved to another Airbnb, which is the subject of the current incident report. That location resulted in the clients and the program being banned due to excessive noise complaints. Following this, the clients were placed in another client's unit, raising concerns about appropriate placement procedures. Further investigation is needed to assess the adequacy of client placement and whether proper discharge procedures were followed. At the time of the visit, both clients had been discharged. One with a 14-day notice and the other with a 24-hour notice due to multiple rule violations. Copies of both exit notices were provided to LPA during the visit. Additional follow-up is required to complete the investigation related to this incident report. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Antonio Pizano, Resource Coordinator.

met_with: Antonio Pizano - Resource Coordinator


summary: Facility Evaluation

raw_content:
Narrative:
On December 16, 2025, Licensing Program Analyst (LPA) Jonathan Medina visited the above-referenced facility to amend a previously issued report. LPA met with Antonio Pizano, Resource Coordinator, and explained the purpose of the visit. The report was amended during the visit. An exit interview was conducted, and both the re-signed amended report and a copy of this visit report were provided to the facility.

met_with: Antonio Pizano, Resource Coordinator.


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Investigation Findings:
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:

report_type: Complaint Investigation

complaint_status: unsubstantiated


summary: Facility Evaluation

raw_content:
Narrative:
On 11/04/2025 at 2: PM, Licensing Program Analyst (LPA) Jonathan Medina conducted a complaint investigation visit to deliver findings. During the course of complaint investigation #14-CR-20250915103941, LPA discovered that another minor was placed in one of the Transitional Housing Placement Program (THPP) units. LPA met with Antonio Pizano, Resource Coordinator, and explained the purpose of the visit. As a result, this is a violation of Health and Safety Code section 1559.110(d)(3). Please refer to LIC 809-D for further information. LPA advised facility that any minor placement into a THPP unit requires prior approval from Licensing for an exception. The supervision plan and the youth's individual needs must be assessed to determine if placement in a THPP unit is appropriate. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Antonio Pizano, Resource Coordinator, whose signature below confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 11/12/2025, Licensing Program Analyst (LPA) Jonathan Medina made a visit to the home to correct licensing documents and amend the deficiency issued to the facility during the initial complaint visit. The amendment was made to reflect the deficiency under a case management inspection instead, as the deficiency was not pertinent to the complaint. Upon entering the facility, LPA met with Mandave Sandhu, Lead Case Manager, and explained the purpose of the visit. During the initial complaint visit for complaint #14-CR-20250915103941 on 9/23/2025, no staff member was available at the time of arrival. LPA returned at 2: PM to conduct the visit with Mandave Sandhu, Lead Case Manager. One deficiency was cited under Section 80044(c) - Inspection Authority of the Licensing Agency. This was a repeat violation, and a civil penalty of $250 was assessed. Please refer to LIC 809-D for additional details. LPA corrected the documentation in the LIC 9099 and LIC 9099-D complaint reports to remove the deficiency and reissued it appropriately under this LIC 809 and attached LIC 809-D. Additionally another document reflecting the $250 civil penalty was made on todays visit. The deficiency was cleared by the facility on 10/28/2025. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Mandave Sandhu, Lead Case Manager. The signature on this report acknowledges receipt.


summary: Facility Evaluation

raw_content:
Narrative:
Control Number - 2562-FN On January 21, 2026, at 2:00 p.m., Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced case management inspection at the above-referenced facility to follow up on an Incident Report (IR) submitted by the facility. LPA Medina met with Ron Dhillon, Licensee. Mandave Sandhu, Lead Case Manager, was also available during the visit over the phone. During the inspection, LPA Medina interviewed staff regarding an incident that occurred on December 30, 2025. According to the Incident Report, several clients were involved in a verbal altercation. The clients reside within the same apartment complex. The report stated that Client C1 went to the apartment of Clients C2 and C3, who are siblings, to address an issue. A verbal altercation occurred. Client C1 reported that Clients C2 and C3 stated they had a firearm. After Client C1 returned to their apartment, the disturbance continued, and law enforcement was contacted. During the inspection, LPA Medina interviewed staff regarding the follow-up actions taken after the incident, as Part Two of the Incident Report had not yet been submitted. LPA Medina also inquired about the facility's response to the reported statement involving a firearm. Lead Case Manager Mandave Sandhu explained that, upon learning of the alleged firearm, he immediately instructed client C1 to contact law enforcement. Mandave Sandhu stated that law enforcement conducted a search of the property and did not locate a firearm. LPA Medina requested a case number; however, the Lead Case Manager stated that law enforcement did not provide one. Continues on LIC809-C LPA Medina will follow up with the Hayward Police Department to verify law enforcement involvement. Mandave Sandhu further stated that he conducted a follow-up welfare check the following day to obtain additional details and conducted a room search. LPA requested if there was any documentation of the check up with the clients and Mandave stated he will email it to LPA by the end of the day once he is back at the office. Mandave Sandhu further explained Client C1 had the altercation with client C3's friend who has been asked to leave the property. Mandave stated no further altercations have been reported as of todays date between all clients involved and client C3s friend has not been seen on premises. LPA Medina determined that the facility conducted appropriate follow-up actions in response to the incident. Additionally, LPA will follow up with the Hayward Police Department to further evaluate law enforcement involvement. No deficiencies were cited during today's visit. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Ron Dhillon, Licensee. Signature on this report acknowledges receipt. LPA also obtained a signature from Ron Dhillon for an attempted visit on 1/14/2026 where LPA interviewed a staff member in the THPP office that also worked at the the programs Group Home. LPA was unable to obtain signature from staff on previous visit.

met_with: Ron Dhillon - Licensee


summary: Facility Evaluation

raw_content:
Narrative:
*** Report amended and resigned on 3/18/2026*** On 01/08/2026 at 12:30 p.m., Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced inspection to issue a deficiency. LPA Medina met with Mandave Sandhu, Lead Case Manager, and explained the purpose of the visit. During a previous inspection, LPA Medina requested the Needs and Services Plans for two clients who were previously placed in the program. The facility reported that a Needs and Services Plan was not completed for one client because the Transitional Independent Living Plan (TILP) had not been provided by the child welfare worker (CCW). During the visit, LPA Medina reviewed regulatory requirements with the facility, including that the TILP must be requested from the placing agency at the time of admission and that a Needs and Services Plan must be completed within 30 days of placement. When the TILP is not immediately available, the facility is required to document attempts made to obtain it. The facility did not have Needs and Services available within 30 days. As a result, the facility is cited in accordance with Title 22, Section 86268.3(a), Needs and Services and Transitional Independent Living Plan (TILP). Refer to LIC 809D for additional information. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Mandave Sandhu, Lead Case Manager. His signature below confirms receipt of this report.


summary: Facility Evaluation

raw_content:
Narrative:
On 03/18/ Licensing Program Analyst (LPA) Jonathan Medina made a visit to the facility to amend a report made on 01/08/2026. LPA met with Program Manager, Manager and informed them of the purpose of the visit. The reports were amended to replace the deficiency. A cleared Plan Of Correction (POC) letter was provided on todays meeting as well. An exit interview was conducted, appeals rights discussed, and a copy of this report was left with the facility. Signature on this report acknowledges receipt.

met_with: Mandave Sandhu - Program Manager


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

raw_content:
Narrative:
Regulations require the stabilization plan to be created before a 14-day exit notice is issued and to include steps to assist the resident in returning to compliance or to coordinate with the placement agency to explore alternative placement options. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Mandave Sandhu, Program Manager, whose signature below confirms receipt.

Investigation Findings:
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:
86087.2(e): (e) All participant living units shall be kept clean, safe, sanitary and in good repair at all times.

met_with: Mandave Sandhu - Program Supervisor

title: Participant Living Units


facility_name: CASA DE AMPARO

summary: Facility Evaluation

raw_content:
Narrative:
On June 7, 2021 at 1: PM, Licensing Program Analyst (LPA) Carol Anderson made an unannounced annual/required visit to the agency and met with Director of Quality of Assurances Erin Gospodarec and Program Director Elyse James. The agency utilizes off-site apartment complexes within the community designated for the Transitional Housing Program Placement participants. Also, there 34 participants currently in placement. The agency employees assigned staff under the Transitional House Placement Program. One Program Director, Four social workers/advocates and one house manager. All employees have the required experience, and training. LPA reviewed 10 participants' files and six staff files; all the required forms are updated in the files. LPA will conduct an on-site inspection participant residence at another date and time. LIC 308, LIC 309, LIC 408 and LIC 500 to be updated and submitted to CCL within 30 days. Reviewed Facility Personnel Report Summary and all staff associated to facility have met Fingerprint and Child Abuse requirements, and facility personnel meet staff training requirements. The facility has demonstrated compliance with Title 22, Division 6 of the California Code of Regulations.

met_with: Erin Gospodarec


summary: Facility Evaluation

raw_content:
Narrative:
On June 22, 2023, at 12: PM, Licensing Program Analyst (LPA) Carol Anderson made an unannounced annual/required visit to the agency and met with Remy Gaither,PHD, Director of THP +Program and Stephanie Donnellan, Residential Administrative Support Manager. The agency utilizes off-site apartment complexes within the community designated for the Transitional Housing Program Placement participants. Also, there are 19 participants currently in placement. The agency employees assigned staff under the Transitional House Placement Program. One Program Director, three Advocate Educators, and one Administrative Housing Coordinator. All employees have the required experience, and training. LPA reviewed five participants' files and five staff files; all the required forms are updated in the files. LIC 308, LIC 309, LIC 408 and LIC 500 to be updated and submitted to CCL within 30 days. Reviewed Facility Personnel Report Summary and all staff associated to facility have met Fingerprint and Child Abuse requirements, and facility personnel meet staff training requirements. Based on the file reviews this date, there are no deficiencies. An exit interview was conducted and a copy of this report and was given to Remy Gaither, PHD, Director of THP Program.

met_with: Remy Gaither


summary: Facility Evaluation

raw_content:
Narrative:
On July 18, 2024, at 12: PM, Licensing Program Analyst (LPA) Carol Anderson made an unannounced annual/required inspection to the facility. LPA met with Stephanie Donnellan, Residential Administrative Support Manager in-person. LPA met with Elyse James, LCSW, Director of Transitional Housing Casa de Amparo via Microsoft Teams. Currently there are 29 participants in placement. The agency utilizes off-site apartment complexes thought-out San Diego County for participants to reside. LPA reviewed the Board of Directors Meeting Minutes for May 9, 2024. LPA reviewed six participants' files and five staff files: all the required forms in the files. A review of Guardian on July 18,2024 indicates that all facility staff associated to the facility had DOJ, FBI, and child abuse index check clearances. Based on the file reviews this date, there are no deficiencies. An exit interview was conducted and a copy of this report and was given to Stephanie Donnellan, Residential Administrative Support.

met_with: Elyse James


facility_name: CASA PACIFICA CENTERS FOR CHILDREN

summary: Facility Evaluation

raw_content:
Narrative:
On 09/25/2024 at 12:14pm, Licensing Program Analyst, (LPA) Christine Wilson made an announced visit for the purpose of conducting a Pre-Licensing Inspection. LPA met with the Director of Transitional Youth Services, and together toured the Stepping Stones (TYS) temporary location on-site cottages and administrative office , The Stepping Stones (TYS) temporary location is located at S Lewis Road in Camarillo. The administrative office is located at Building N, S Lewis Road in Camarillo. The Facility Administrator and Clinical Program Manager's Office is located in the main Casa Pacifica Campus Administrative Office. The facility is licensed to provide Transitional Housing Placement plus Foster Care (THP + FC) and Non-Minor Dependents (NMD) to 20 participants ages eighteen (18) to twenty one (21). There are currently (9) participants waiting to be relocated from the original THPP location.. LPA Wilson inspected two cottages: McDonald's and Angels Cottages, which are newly renovated and have an identical physical plant footprint as follows: Report continued on LIC809C page LPA Wilson inspected the following: Each building has (2) bedroom suites with on-suite full bathrooms. Clean linens, drawers, cabinets, desk and chair and has a functioning smoke detector with carbon monoxide detector and thermostat in working condition. Water temperature tested to be within range. Each building has (7) additional bedrooms for one client. Beds have clean linens, drawers, cabinets, desk and chair and has a functioning smoke detector with carbon monoxide in working condition. Water temperature tested to be within range. There are (3) fire extinguishers available. External thermostat controls for the additional bedrooms is located adjacent to the kitchen There are (4) all-gender bathrooms with sink toilet and shower/tub. Water temperature tested to be within range. Each building has a kitchen with full sized freezer set at 8 degrees, refrigerator at 36 degrees, additional cabinets for each participant's non perishable items, First Aid kit observed to have all items. The kitchens were stocked with pots, pans, cooking utensils, and enough dishes for participants, air fryer, toaster oven, microwave and dishwasher, all tested to be within working condition. There is a telephone line in the kitchen and additional fire extinguisher. Each building has a laundry room with (3) washers and (3) dryers, additional towels and laundry detergents. Per the Facility Maintenance Manager, additional cabinetry will be added to this area in each building. Each building has a counseling/clinical room for private session and phone calls. No files are kept in this room. Room has (1) desk, (1) table and (5) chairs. Each building has a water filtration station in working condition. Each building has a living room area with (2) couches for (10) persons, television and small tables. Games and books were observed to be available. Each building has a game room with gaming consoles, (2) gaming chairs, (1) bean bag and (4) large chairs with small tables. There is a dining area with (3) tables and (12) chairs. All rugs were non-slip and in good condition. Report continued on LIC809C page Page LPA Wilson received a copy of the LIC500, and client roster, copy of fire inspection record cards for McDonalds and Angel Cottages. Per the Facility maintenance manager both buildings have obtained full clearance from the Ventura County Inspector of building and safety. An email was sent to LPA Wilson indicating that the new building project is finalized and has passed inspection. Certificates of Compliance, job descriptions and Intake Assessment Forms were reviewed. An LIC200 for a capacity of (20) clients served was submitted on 09/18/24 and the licensing fee was dropped off to the Regional Office on 09/19/24. There are no deficiencies to be cited at this time. Exit interview was conducted and a copy of this report was left at the facility.


summary: Facility Evaluation

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Narrative:
On December 23, 2024 at 9:16am, Licensing Program Analyst, (LPA) Christine Wilson made an announced visit for the purpose of conducting a Post-Licensing Inspection. LPA Wilson met with the Director of Transitional Youth Services,and TYS Stepping Stones Program Supervisor, and together toured the Stepping Stones (TYS) location on-site cottages and administrative files. , The Stepping Stones (TYS) temporary location is located at S Lewis Road in Camarillo. The administrative office is located at Building N, S Lewis Road in Camarillo. The Facility Administrator and Clinical Program Manager's Office is located in the main Casa Pacifica Campus Administrative Office. The facility is licensed to provide Transitional Housing Placement plus Foster Care (THP + FC) and Non-Minor Dependents (NMD) to 20 participants ages eighteen (18) to twenty one (21). There are currently (11) eleven participants residing in the facility. LPA Wilson inspected two cottages: McDonald's and Angels Cottages, which were newly renovated and have an identical physical plant footprint as follows: Report continued on LIC809C page Page Each building has (2) bedroom suites with on-suite full bathrooms. Clean linens, drawers, cabinets, desk and chair and has a functioning smoke detector with carbon monoxide detector and thermostat in working condition. Water temperature tested to be within range. Each building has (7) additional bedrooms for one client. Beds have clean linens, drawers, cabinets, desk and chair and has a functioning smoke detector with carbon monoxide in working condition. Water temperature tested to be within range. There are (3) fire extinguishers available. External thermostat controls for the additional bedrooms is located adjacent to the kitchen There are (4) all-gender bathrooms with sink toilet and shower/tub. Water temperature tested to be within range. Each building has a kitchen with full sized freezer set at 7 degrees, refrigerator at 35 degrees, additional cabinets for each participant's nonperishable items, First Aid kit observed to have all items. The kitchens were stocked with pots, pans, cooking utensils, and enough dishes for participants, air fryer, toaster oven, microwave and dishwasher, all tested to be within working condition. There is a telephone line in the kitchen and additional fire extinguisher. Each building has a laundry room with (3) washers and (3) dryers, additional towels and laundry detergents. Per the Facility Maintenance Manager, additional cabinetry will be added to this area in each building. Each building has a counseling/clinical room for private session and phone calls. No files are kept in this room. Room has (1) desk, (1) table and (5) chairs. Each building has a water filtration station in working condition. Each building has a living room area with (2) couches for (10) persons, television and small tables. Games and books were observed to be available. Each building has a game room with gaming consoles, (2) gaming chairs, (1) bean bag and (4) large chairs with small tables. There is a dining area with (3) tables and (12) chairs. All rugs were non-slip and in good condition. Report continued on LIC809C page Page LPA Wilson received a copy of the LIC500, and LIC9020 client roster. Both cottages have obtained full clearance from the Ventura County Inspector of building and safety. LPA Wilson observed several First Aid Kit complete with scissors, tweezers, thermometer, gauzes, antiseptic and a 1st Aid Manual in the staff office, medication cabinet, and garage. All posting requirements were met (food menu, regulations, licenses, emergency disaster plan, Children's Personal Rights, and Ombudsman). The Emergency Evacuation Plan is posted). Each cottage has (2) working telephones for client use and youths can use the telephone unless they have their own. Clients have support to own checking and savings accounts and encouraged to save $50 month from either earnings from work or from allowance. LPA Wilson Interviewed (1) client (C1) and (1) staff (S2). LPA Wilson requested the following forms for review, Register of Youth (LIC 9020), Current Census, Personnel Report (LIC 500), written menus, staff weekly and schedule. LPA Wilson ensured Administrator Certificate was current. LPA reviewed the Personnel Report (LIC 500) and confirmed that Direct Care Staff Ratio present for the eleven (11) clients in placement. LPA confirmed that all staff have required criminal record clearance. DOJ, FBI and Child Abuse Response, which meet qualification A review of Facility's Personnel Report Summary on 12/23/2024 indicates that all personnel have criminal record clearance has obtain the necessary clearances with DOJ, FBI, and Child Abuse Response. There are no deficiencies to be cited at this time. Exit interview was conducted and a copy of this report was left at the facility.

met_with: Director of Transitional Youth Services


summary: Facility Evaluation

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Narrative:
On 8/20/2025, at 10: AM Licensing Program Analyst (LPA) Andrew Upshaw made an unannounced inspection to the above-mentioned facility, for the purpose of conducting a Case Management inspection to investigate a self reported incident regarding a client death on 8/18/2025. LPA Upshaw met with Program Supervisor, Victor Juarez (S2), who granted access to the facility. At 10: AM, LPA conducted a walk through of the facility to conduct a health and safety check. LPA interviewed S2, S3, S4, S5, S6, S7, C3, and C4 in person during today's inspection. Statements were obtained and details about the incident were gathered. LPA Upshaw requested and obtained the client roster, intake records, SIRs and LIC500. Based on the interviews conducted and information obtained during today's inspection, further investigation and interviews are required on the above incident. Exit interview was conducted and a copy of this report was emailed to Program Supervisor, Victor Juarez.

met_with: Program Supervisor, Victor Juarez


summary: Facility Evaluation

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Narrative:
On 9/11/2025 at 11:50am Licensing Program Analyst (LPA) Nancy O'Connell made an unannounced visit inspection to the above listed facility for the purpose of conducting an Annual/Required Inspection. LPA met with Theresa Plante, Regional Director, who granted access to the facility and toured the office together. The facility is located on the south-side portion of the larger organizational property. The facility has a staff office that is set up with three desk cubicles, a main desk area, locked file cabinets, and four computer stations. Required postings were observed. This area is utilized as a multipurpose office to complete client intakes, and various client-centered appointments. The facility also contains two cottages, each with the ability to house 10 clients. During the time of inspection, LPA conducted a walk through of the two cottages and observed that each cottage meets regulatory requirements. Each cottage contains a large living room, individual bedrooms equipped with beds, dressers/closets, and adequate lighting. Each cottage also contains a large kitchen with working appliances, a laundry room with washers/dryers, and a designated staff office for private phone calls or meetings. During the inspections, LPA completed the following sections of the THPP Care Tool: Physical Plant, Operations, Disaster Preparedness, and client records. LPA reviewed the client record for C1. See LIC811, dates 9/11/25, for names. Based on the California Code of Regulation, there are no deficiencies to be cited today. Due to time constraints, LPA will return on another day to complete the inspection. An exit interview was conducted and a copy of this report was emailed to the facility administrator.

met_with: Theresa Plante, Regional Director


summary: Facility Evaluation

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Narrative:
On 9/16/2025 at 9:00am Licensing Program Analyst (LPA) Nancy O'Connell made an unannounced visit inspection to the above listed facility for the purpose of conducting an Annual/Required Inspection. LPA met with Victor Juarez, Facility Administrator (FA)who granted access to the facility and toured the office together. LPA met with FA and informed him that the purpose of the visit is to complete the continuation of the Annual inspection. LPA inquired about the current census, and requested the Register of Clients, and a staff roster. LPA requested to interview selected client and staff files. LPA conducted staff and client interviews, see LIC811, dated 9/16/25, for names. During the inspections, LPA completed the following sections of the THPP Care Tool: Client Records and Staff Records. LPA reviewed the following client records: C3, C5, C9, C10, and C11. LPA reviewed the following staff records: FA, RD, S1, S2, and S3. LPA interviewed/attempted to interview: FA, S1, S3, C5 (declined), C6 (declined), C7, C12, C C14 (declined). Per California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulation, there are no deficiencies cited during this inspection. LPA informed FA that the annual inspection is complete. An exit interview was conducted and a copy of this report was emailed to the facility administrator.

met_with: Victor Juarez, Facility Adminsitrator (FA)


summary: Facility Evaluation

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Narrative:
On 11/4/25, at 9:00am, Licensing Program Analyst (LPA) Nancy O'Connell arrived at the above listed facility and conducted an announced Case Management Inspection-Other. LPA met with Victor Juarez, Facility Administrator (FA). The purpose of this inspection was to conduct a health an safety check on the facility's new additional cottage, prior to processing a capacity increase. During the time of inspection, LPA O'Connell and FA conducted a tour of the cottage, inside and out. The cottage is one of three cottages on the facility property and has an identical floor plan to the two preexisting cottages. This cottage will be designated to accept Non-Minor Dependents (NMD) who have a child/children. The program will also allow clients to have their spouses/partners live with them upon program approval and assessment for safety. FA confirms that all persons residing in the THPP will be accounted when assessing capacity limits. The cottage is setup with nine (9) bedrooms and six (6) bathrooms. There is a laundry room, a playroom setup with children's toys, a dining area, a communal living room area and a staff office that can also be used a counseling office/location for confidential meetings/phone calls. The kitchen is fully equipped with functional appliances (refrigerator, stove, dinnerware, utensils, microwave, toaster, storage space, etc.). There are multiple fire extinguishers observed throughout the cottage as well as a sprinkler system inside the cottage. All bedrooms were set up with 1-2 beds, mattresses, bedding, pillows, dressers, portable closets, rugs, mirrors, and trash cans. There are multiple phones in the cottage that may be used by clients. FA confirms that cribs and carseats are available for any client who may need them upon intake. LPA and FA conducted a tour of the exterior portion of the property and LPA observed two access gates that lead into the main campus area. LPA inquired about plan for monitoring client access to the gates and staff Continued on LIC809C confirmed that gates would be alarmed in order to ensure separation of facility clients from clients residing in placement programs for minors. There are also facility cameras that monitor the entry gates. Per California Code of Regulations, there are no deficiencies cited at this time. An exit interview was conducted and a copy of this report was sent to the


summary: Facility Evaluation

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Narrative:
On 2-19-26, at 9:00am, Licensing Program Analyst (LPA) Nancy O'Connell arrived at the above listed facility and conducted an announced Case Management Inspection-Other. LPA met with Victor Juarez, Facility Administrator (FA), and Theresa Plante, Regional Director (RD). The purpose of this inspection was to conduct a health and safety check on one of the facility's cottages, prior to processing a capacity increase. During the time of inspection, LPA O'Connell inspected one (1) out of the three (3) cottages- Caldwell Cottage. This cottage will be designated to accept Non-Minor Dependents (NMD) who have a child/children. The program will also allow clients to have their spouses/partners visit them for specified periods of time, upon program approval and assessment for safety. FA confirms that all persons residing in the THPP will be accounted for when assessing capacity limits. The setup of Caldwell Cottage has nine (9) bedrooms and six (6) bathrooms. There is a playroom setup with children's toys, a laundry room, a dining area, a communal living room area and a staff office that can also be used as a confidential location for meetings/phone calls. The kitchen is equipped with functional appliances (refrigerator, stove, dinnerware, utensils, microwave, toaster, storage space, etc.). There is multiple fire extinguishers observed throughout the cottage as well as a sprinkler system inside the cottage. All bedrooms were set up with 1-2 beds, mattresses, bedding, pillows, dressers, portable closets, rugs, mirrors, and trash cans. There are multiple phones in the cottage that may be used by clients. There is also a laundry room included, equipped with washers, dryers, a cabinet for detergents/irons. During the time of inspection, LPA observed materials and furnishings available for the minor children of the participants. Items included: (mini) crib, changing table, toddler bed, and high chairs. FA explained that all bedrooms will be equipped to accept children, with additional beds available for visitors as needed. FA confirms that cribs and car seats are available for any client who may need them upon intake. Lastly, there are exterior cameras pointed at all exit doors to the cottage. Continued on LIC809C Items addressed: Laundry Room and Kitchen: doors leading to the laundry room and kitchen would be secured with a lock, to ensure that children of the non-minor dependents do not have access to harmful items. Per California Code of Regulations, there are no deficiencies cited at this time. An exit interview was conducted and a copy of this report was sent to the Administrator.


facility_name: CASA PACIFICA THP + FC

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Narrative:
On 03/08/2022, the Department received a complaint alleging Nonminor Dependent#1 (NMD1) is being discriminated because of their race, and that residents smoke marijuana on the premises. LPA Rosas conducted interviews with residents, staff, and pertinent parties regarding to allegations. Facility program is designed to prepare residents to live independently by assist them with budgeting, employment, life skills, and educational goals. LPA Rosas during inspection observed adequate ratio that followed regulations. Confidential interviews and documentary evidence did not indicate that staff failed to supervise or discriminate residents in placement. There was not enough evidence and information to corroborate the allegations of Neglect and Lack of Supervision and Personal Rights violations. Results from the Department's investigation, consisting of interviews with related parties, inspections, and review of records. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations is unsubstantiated. The Department has decided that the allegations of Neglect/Lack of Supervision and Personal Rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There were no deficiencies observed or cited at this time. Exit interview was conducted with S1 and a copy of this report was left at the facility.

Investigation Findings:
13On March 9, 2023, at 9:45am, Licensing Program Analysts (LPAs) Olivia Rosas and Christine Wilson conducted an unannounced inspection to Casa Pacifica- Stepping Stones THP + FC (Transitional Housing Placement Program) for the purpose of concluding the investigation on the above allegations and to deliver the findings. LPA Rosas, met with Staff#1 (S1) and together discussed the investigation details. During the investigation process, LPA Rosas interviewed witnesses and pertinent parties related to the investigation. Individuals mention in this complaint are identify on the Confidential Names List (LIC811) dated 03/09/2023. Based on the confidential interviews conducted during the investigation process, record review, statements obtained, LPA Rosas concluded the allegations of client's smoke Marijuana on the premises and staff are discriminating against a client. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the findings are unsubstantiated. Report continues LIC-9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Olivia Rosas 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 31-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, VENTURA BLVD., STE. WOODLAND HILLS, CA FACILITY NAME: CASA PACIFICA THP + FCFACILITY NUMBER: VISIT DATE: 03/09/2023

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

met_with: Staff#1 (S1)


raw_content:
Investigation Findings:
13On 04/25/2024 at 03:11PM Licensing Program Analyst (LPA) Jhane Haynes made an unannounced inspection to the above facility for the purpose of concluding the investigation on the above allegation and deliver the complaint findings. LPA spoke with Christan Schuler (Perez) Administrator and together discussed the investigative findings. During the investigation LPA Haynes interviewed and accounted for all relevant parties. Interviews reflected staff did not adhere to defensive driver policy. Based on interviews and record review, the preponderance of evidence standard has been met; therefore the above allegation is found to be SUBSTANTIATED. Per Title Division Chapter 1, one deficiency will be cited today. See LIC9099-D for details. An exit interview was conducted, and a copy of this report and appeal rights was emailed to the administrator. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Jhane Haynes LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION WOODLAND HILLS S.Ro, Ventura Blvd., STE. WOODLAND HILLS, CA This is an official report of an unannounced visit/investigation of a complaint received in our office on 12/14/2023 and conducted by Evaluator Jhane Haynes COMPLAINT CONTROL NUMBER: 31-CR- FACILITY NAME:CASA PACIFICA THP + FCFACILITY NUMBER: ADMINISTRATOR:LEPORE, JOSHUAFACILITY TYPE: ADDRESS: S. LEWIS ROADTELEPHONE: (805) 366- CITY:CAMARILLOSTATE: CAZIP CODE: CAPACITY:30CENSUS: 6DATE: 04/25/ UNANNOUNCEDTIME BEGAN: 03: PM MET WITH:Christan Schuler (Perez) Administrator TIME COMPLETED:03: PM 9Facility staff speak inappropriately to resident(s). INVESTIGATION FINDINGS: 13On 04/25/2024 at 03:11PM, Licensing Program Analyst (LPA) Jhane Haynes made an unannounced inspection to the above facility for the purpose of concluding the investigation on the above allegation and deliver the complaint findings. LPA spoke with Christan Schuler (Perez) Administrator and together discussed the investigative findings. During the investigation LPA Haynes interviewed and accounted for all relevant parties. Based on interviews, facility staff speak to participants with respect and professionalism. Statements to corroborate the above allegation could not be obtained. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore is UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was emailed to the administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Jhane Haynes LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 2 of Control Number 31-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION WOODLAND HILLS S.Ro, Ventura Blvd., STE. WOODLAND HILLS, CA FACILITY NAME: CASA PACIFICA THP + FCFACILITY NUMBER: 565801918

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

met_with: Christan Schuler (Perez) Administrator


raw_content:
Narrative:
Page Further, key witnesses that could determine the validity of the allegation (1) were either not available or declined to be interviewed. The above allegations are unsubstantiated meaning, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the finding is unsubstantiated. There are no deficiencies to be cited, at this time. Exit Interview conducted, and a copy of this report was left at the facility.

Investigation Findings:
13On December 11, 2024 at 11:46 am, Licensing Program Analyst (LPA) Christine Wilson made an unannounced visit to the above listed facility for the purpose of concluding the investigation on the above allegations. LPA met with the Director of TYS THP Administrator. Based on the confidential interviews with all relevant persons, conducted during the investigation process,record review, and statements obtained, LPA Wilson concluded the allegations are unsubstantiated. During the investigative process by both LPA Haynes and LPA Wilson, relevant parties have been accounted for. There are other smoke detectors and carbon monoxide detectors in the cottage related to allegations(2-3), such that the requirement was met. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Christine Wilson LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 31-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION WOODLAND HILLS S.Ro, Ventura Blvd., STE. WOODLAND HILLS, CA FACILITY NAME: CASA PACIFICA THP + FCFACILITY NUMBER: VISIT DATE: 12/11/2024

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

met_with: Director of TYS THP Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 09/01/2021, Licensing Program Analyst, (LPA) Kevin Sauk made an unannounced visit for the purpose of conducting an Annual Required Inspection. LPA met with the Housing Manager and together toured the administrative office and the two on-site homes. The administrative office is located at 1728B - Resource Center. The office is set up as follows: Sitting area with 2 computers, a conference table/interview area and a restroom. To the left there is the Transitional Facilitator office, equipped with 3 computers, where the two (2) clinicians, and one (1) Transitional Facilitator / Case Manager work. Through the Transitional Facilitators office, there is a kitchenette that leads to the office of the Housing Supervisor. Housing clients records and the Outpatients Program records are maintained in the housing supervisor's office. The Facility Administrator and Clinical Program Manager's Office is located in the main Casa Pacifica Campus Administrative Office. The facility is licensed to provide Transitional Housing Placement plus Foster Care (THP + FC) and Non-Minor Dependents (NMD) to 30 participants ages eighteen (18) to twenty one (21). There are currently ten (10) participants in placement including two remote sites, located in Ventura and Oxnard. The Ventura remote-site may house up to four (4) participants, and the Oxnard remote-site may house up to 3 participants. There are currently 2 participants in the Oxnard location, and there are 3 participants in the Ventura location. The Administrative office is located on the Casa Pacifica premises. The two (2) THP+FC single-site models are also located on the Casa Pacifica premises; one is located at 1728A Lewis Road, Camarillo, CA, 93012 which is a house that has 3 dual occupancy bedrooms and 2 bathrooms; the other one is located on 1728C Lewis Road, Camarillo, CA. 93012, which has 2 single occupancy rooms, and one bathroom. (Continued on LIC809-C, page 2) During the inspection of the single-site models located on the premises of Casa Pacifica, LPA observed the following: 1728A: "Vicki's Place" has 3 double occupancy bedrooms, 1 single occupancy bedroom, 2 bathrooms, living room, dining area and kitchen. There are currently 4 participants, along with one infant, residing at this site. LPA observed this site to be clean, safe, and in good repair. LPA observed the fire extinguisher to be fully charged, and the smoke alarm / carbon monoxide detector to be functional. The first aid kit was fully stocked, and the outdoor area was free and clear of any obstructions. 1728C: "Baker's Place" has 2 single occupancy bedrooms, 1 bathroom, living room, dining area and a kitchen. There are currently 1 participant, along with an infant and a toddler, residing at this site. LPA observed this site to be clean, safe, and in good repair, except that the site should be baby-proofed to prevent the baby from accessing cabinets, drawers, and electrical sockets. Due to time constraints, LPA Sauk shall return on another date to complete file reviews and interviews. There are no deficiencies to be cited at this time. Exit interview was conducted and a copy of this report was left at the facility.

met_with: Housing Supervisor (HS)


summary: Facility Evaluation

raw_content:
Narrative:
On March 9, 2023, at 9:45am, Licensing Program Analysts (LPAs) Olivia Rosas and Christine Wilson conducted an unannounced inspection to Casa Pacifica Stepping Stones: THP + FC (Transitional Housing Placement Program) for the purpose of conducting Case Management- Incident inspection to gather additional information regarding the Unusual Incident/Injury Report (SIR) dated 03/03/2023. LPAs Rosas and Wilson, met with Staff#1 (S1) to discuss discussed the details SIR dated 03/03/2923. Individuals mention in this complaint are identify on the Confidential Names List (LIC811) dated March 9, 2023, at 9:30am. The Department received SIR dated 03/03/2023, where it was disclosed that S1 discovered two (2) video and large quantity of photo content in the storage of Staff#2 (S2) work issued cell phone containing communication from Client#1 (C1). Facility in addition, submitted Report of Suspected Dependent Adult and Social Worker was contacted. Facility reported, no Law Enforcement report was submitted. Facility described the nature of the photos and pictures where staff was found to have cross boundaries with C1. Facility terminated S2 due to violating Casa Pacifica staff conduct policies on 03/06/2023. Based on the interviews conducted and information obtained during today's inspections, no further investigation or interviews are required on the above incident. LPAs interview Staff#2 (S2), Staff#3 (C3) and resident decline to be interview. This case management investigation is closed. here were no deficiencies cited at this time. Exit interview was conducted with S1 and a copy of this report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 01/30/2024 at 2:05PM Licensing Program Analyst (LPA) Christine Wilson made an unannounced visit to Casa Pacifica Transitional Housing Placement plus Foster Care (THP + FC) Administrative Office for the purpose to conduct the Annual/Required licensing Inspection. LPA Wilson met with Program Supervisor (PS) who granted access to the Administrative Office and an inspection was conducted together. Individuals mentioned in this report are identify on the Confidential Names List (LIC811) dated 01/30/24. The annual fees are current. LPA Wilson inspected following: The facility is licensed to provide Transitional Housing Placement plus Foster Care (THP + FC) and Non-Minor Dependents NMD) to thirty (30) participants. There is a Nalazone waiver on file. There are currently seven (7) participants in placement at (2) different sites (site A and site B are located on the premises of Casa Pacifica. There are no off-site locations during the time of this inspection). There are no participants on a placement waitlist. Facility has one (1) Case Management Social Worker (SW) (1 per 7 participants) and one (1) Facility Supervisor and one (1) Facility Administrator (1 per Social Workers). The facility is currently operating within staff ratio. The administrative office is located at S. Lewis Road, Camarillo, CA 93012. The office is located in proximity to the sites and is set up as follows: Administration office is a two (2) room office with Resource Center area. The Resource area is used by staff and clients for program use. There are three (3) desks used by staff, Program Superisor and case carrying social worker, large table and chairs, TV, Microwave, refridgerator, and AC unit. The second office has an adjacent kitchenette with refrigerator and microwave. The Adminisrtrator Office is equipped with one (1) desk used by the Program Director and has locked file cabinets for client files, and a heater with thermostat. This office is available to conduct private interviews. Staff records are maintained in the Human Resource office and the client records are maintained in the Program Director's office space inside locked file cabinets. All posting requirements were met. Continues on 8009C Page 2 of Page LPA Wilson, requested the following forms for review, copy of applicable waiver and exceptions, Register of participants, Current Census, Personnel Report (LIC 500), Emergency Disaster Plan Protocols, Emergency Disaster Plan for Children's Residential Facilities (LIC 610C). There are (2) current Certificates of Compliance for (2) individual units A and B are which are occupied. Due to time constraints, LPA Christine Wilson will return to complete the inspection to and inspect the following: Site A and B inspection, Staff Records Review, Clients Records Review, Staff Interviews, and Client Interviews There are no deficiencies at this time. Copy of report was read with Program Supervisor and left on site.

met_with: Program Supervisor


summary: Facility Evaluation

raw_content:
Narrative:
On 02/08/2024 at 9:41AM Licensing Program Analyst (LPA) Christine Wilson made an unannounced visit to Casa Pacifica Transitional Housing Placement plus Foster Care (THP + FC) Administrative Office for the purpose to conclude the Annual/Required licensing Inspection. LPA Wilson met with Program Supervisor (PS) who granted access to the Administrative Office and an inspection was conducted together. LPA Wilson inspected following: During the inspection of the single-site models located on the premises of Casa Pacifica, LPA observed the following: 1728A: "Vicki's Place" has 3 double occupancy bedrooms, 1 single occupancy bedroom, 2 bathrooms, living room, dining area and kitchen. There are currently 5 participants, residing at this site and one resident was reported to currently be placed on 5150 hold. LPA observed the common areas of this site to be clean, and safe except that the lights in laundry room should be observed for dead bugs removal by maintenance. Occupant door missing to one bedroom. LPA observed the fire extinguisher to be fully charged, and the smoke alarms in bedrooms / carbon monoxide detector to be functional. The first aid kit was fully stocked, and the outdoor area was free and clear of any obstructions. 1728B: "Baker's Place" has 2 single occupancy bedrooms, 1 bathroom, living room, dining area and a kitchen. There are currently 2 participants, along with 2 allowable pets, residing at this site. LPA observed this site to be, safe, and in good repair, except that the site should be observed for mildew in the bathroom by maintenance. A review of Facility's Personnel Report Summary on 02/08/2024 indicates that all personnel have criminal record clearance has obtain the necessary clearances with DOJ, FBI, and Child Abuse Response. Continued on 809C page 2 of Page Staff Records Review: LPA inspected (3) three staff files and ensured Administrator Certificate was current. LPA reviewed the Personnel Report (LIC 500) LPA confirmed that all staff have required criminal record clearance. DOJ, FBI and Child Abuse Response, which meet qualification. (1) Theraputic Crisis Intervention (TCI), Emergency Disaster Training, (3) Mandated Reporter. (3)CPR/First Aid/AED training certificates were observed. There is no qualified, licensed professional social work staff at this facility. Clients Records Review: LPA Wilson reviewed three (3) clients records () which meet requirement. LPA reviewed the Needs and Services Plan (ILP), Allowance Log, Emergency Contact information, Incident Reports and Medical Records. Emergancy Plans Review: LPA observed Emergency Management procedures, LIC610C and emergency list of clients and medications, ILP for emergencies. 11:26am Staff Interviews: LPA Wilson conducted a confidential interviews with two (2) on duty staff ((PS and CM)). Vehicle: Vehicles are a Chevy Traverse and a Nissan Sentra with current registration, Insured by Ace American Insurance and in good working condition. There is (1) deficiencies to be cited at this time (see LIC809D). Exit interview was conducted and a copy of this report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On 06/19/2024 at 10:27am, Licensing Program Analyst (LPA) Christine Wilson, made an unannounced visit to the above listed facility, and met with the THPP Program Director, in order to conduct a case management incident inspection, regarding SIR dated 06/17/2024. During the course of the incident investigation, it was revealed that on 06/17/2024, the NMD client (C1) who currently resides in CASA Pacifica Transitional Housing, reported to staff (PD) that she has been pressured into having sex with another NMD participant (C2) in the housing program, but denies the sexual activity is rape, and even though (C1) tells (C2) no, the sexual activity still happens. Further, this has not been reported to the police because (C1) does not want to make a police report. Staff have provided support to file a police report, a safety plan with boundaries and coaching, disclosing how a shared living agreement will be moving forward and well as dating and relationship policy review and referring (C1) to CSEC Forever Found Community Partner. Staff have provided case management, including discussion about intimacy with house mates, the dating and relationship policy, and the risks associated with sexual activity with client (C2). Staff will ensure clients are not transported together and will be increasing on-call staff in the evening. Per the (PD) the structure of living in the temporary location with not be co-ed. Further the (PD) stated the construction for the temporary THPP location start and end of construction date will change due to water damage found, leading to the sub-flooring needing to be replaced and permit clearance needed. Clients will not transfer to the temporary location until permits and project completion. There are no deficiencies cited today. An exit interview was conducted, and a copy of this report was emailed to the licensee.

met_with: THPP Program Director


summary: Facility Evaluation

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Narrative:
On 09/18/2024 at 9:30am, Licensing Program Analyst, (LPA) Christine Wilson and Licensing Program Manager, (LPM) Kevin Sauk made an announced visit for the purpose of conducting a Pre-Licensing Inspection. LPA and LPM met with the Director of Transitional Youth Services, CEO, Compliance and Risks Manager, Facility Maintenance Manager and the Regional Director of Ventura County, and together toured the Stepping Stones (TYS) temporary location on-site cottages and administrative office , The Stepping Stones (TYS) temporary location is located at S Lewis Road in Camarillo. The administrative office is located at Building N, S Lewis Road in Camarillo. The Facility Administrator and Clinical Program Manager's Office is located in the main Casa Pacifica Campus Administrative Office. The facility is licensed to provide Transitional Housing Placement plus Foster Care (THP + FC) and Non-Minor Dependents (NMD) to 20 participants ages eighteen (18) to twenty one (21). There are currently (9) participants waiting to be relocated from the original THPP location.. LPA Wilson and LPA Sauk inspected two cottages: McDonald's and Angels Cottages, which are newly renovated and have an identical physical plant footprint as follows: Report continued on LIC809C page At 9:50 am LPA Wilson and LPM Sauk inspected the following: Each building has (2) bedroom suites with on-suite full bathrooms. Clean linens, drawers, cabinets, desk and chair and has a functioning smoke detector with carbon monoxide detector and thermostat in working condition. Water temperature tested to be within range. Each building has (7) additional bedrooms for one client. Beds have clean linens, drawers, cabinets, desk and chair and has a functioning smoke detector with carbon monoxide in working condition. Water temperature tested to be within range. There are (3) fire extinguishers available. External thermostat controls for the additional bedrooms is located adjacent to the kitchen There are (4) all-gender bathrooms with sink toilet and shower/tub. Water temperature tested to be within range. Each building has a kitchen with full sized freezer set at 8 degrees, refrigerator at 36 degrees, additional cabinets for each participant's non perishable items, First Aid kit observed to have all items. The kitchens were stocked with pots, pans, cooking utensils, and enough dishes for participants, air fryer, toaster oven, microwave and dishwasher, all tested to be within working condition. There is a telephone line in the kitchen and additional fire extinguisher. Each building has a laundry room with (3) washers and (3) dryers, additional towels and laundry detergents. Per the Facility Maintenance Manager, additional cabinetry will be added to this area in each building. Each building has a counseling/clinical room for private session and phone calls. No files are kept in this room. Room has (1) desk, (1) table and (5) chairs. Each building has a water filtration station in working condition. Each building has a living room area with (2) couches for (10) persons, television and small tables. Games and books were observed to be available. Each building has a game room with gaming consoles, (2) gaming chairs, (1) bean bag and (4) large chairs with small tables. There is a dining area with (3) tables and (12) chairs. All rugs were non-slip and in good condition. at 11:06am, LPA and LPM met with the Director of Transitional Youth Services, CEO, Compliance and Risks Manager, and the Regional Director of Ventura County in the administrative building and discussed the Plan of Operation. Report continued on LIC809C page Page LPA Wilson and LPM Sauk received a copy of the LIC500, and client roster, copy of fire inspection record cards for McDonalds and Angel Cottages. Per the Facility maintenance manager both buildings have obtained full clearance from the Ventura County Inspector of building and safety. An email was sent to LPA Wilson and LPM Sauk indicating that the new building project is finalized and has passed inspection. Certificates of Compliance, job descriptions and Intake Assessment Forms were reviewed. An LIC200 for a capacity of (20) clients served was submitted today to LPA Wilson and LPM Sauk. There are no deficiencies to be cited at this time. Exit interview was conducted and a copy of this report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On September 25, 2023 at 2:15 pm, Licensing Program Analyst (LPA) Christine Wilson made an unannounced visit to the above listed facility, in order to conduct a case management incident inspection, regarding SIR dated 09/20/24. During the course of the incident investigation, it was revealed that on 09/20/24 the Group Home youth (C1) was awol from the facility, which resulted in Group Home youth (C1 visiting with THPP NMD (C2) in their house. Intake facility Manager was notified and saw youth on camera and and called for staff to conduct a perimeter check, where youth was found exiting the house and was escorted back to the Group Home. LPA Wilson and Director of Transitional Youth Services walked the perimeter of the Stepping Stones program, observed the fence and camera. LPA Wilson obtained copy of the SIR, timeline and determined that staff acted quickly to supervise and locate youth. There are no deficiency to be cited at this time. An exit interview was conducted and a copy of this report was discussed and left with licensee. (S1) whose signature on this form confirm receipt of these documents.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/20/23 at 01: PM Licensing Program Analyst (LPA) Jhane Haynes made an unannounced visit to the above facility for the purpose of conducting an initial complaint investigation inspection (See LIC9099 dated 12/20/23). During walkthrough, LPA observed the facility not free and clear of clutter and debris. Hallway was observed to have debris alongside walls and in corners, bathroom smelled of mildew, cluttered with empty products, shower observed to have growth in corners of grout and kitchen sink containing dishes and food particles. Per California Code Regulation Title 22, Division 6, Chapters General Licensing Regulations, one deficiency will be cited today. See LIC809-D for details. An exit interview was conducted and a copy of this report was left with DTYS.

met_with: Christan Perez DTYS


facility_name: CENTRAL VALLEY COMMUNITY RESOURCES, THP+FC

summary: Facility Evaluation

raw_content:
Narrative:
On this date, an unannounced Required Annual Inspection was conducted by Licensing Program Analyst (LPA) Rachel Bruce. LPA was met at Sylvan Ave, Suite A-5 by Administrator Arlene Figueroa-Morales. Currently the agency services THP+FC participants, employs one part time case manager and one full time Administrator. LPA observed agency has appropriate office space for staff and meetings, and confidential files are locked and maintained appropriately. The two staff files were reviewed on today's visit. LPA observed that all files had required documentation and were in compliance with regulations. All staff are appropriately fingerprint cleared and associated. Five client files were reviewed at today's inspection. Required documentation was present and were in compliance with regulations except for no Needs and Services Plan and no Medical Assessment. Citation for those violations will be issued on today's date.

met_with: Arlene Figueroa-Morales


summary: Facility Evaluation

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Narrative:
On today's date, Licensing Program Analysts LPA- Rachel Bruce and Brianna Placencia arrived at the above facility for the purpose of clearing the Plan of Correction for the annual inspection completed on November 7, 2022. Paperwork to clear the deficiencies issued on November 7, 2022 were provided and the plan of corrections were cleared.


summary: Facility Evaluation

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Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at the Central Valley Community Resources THP+FC at Sylvan Ave, Suite A-5 for the purpose of conducting an unannounced Annual Required inspection. LPA met with Administrator, Arlene Figueroa-Morales. A walk through inspection of the facility was conducted. The Agency currently has 8THP+FC participants, employs one Social Worker and one full time Administrator. A file review was conducted on January 31, 2025, presented 0 deficiencies within the past 12 months. A review of Guardian indicates that all facility staff associated and identified on the LIC500 have eligible clearance. LPA reviewed Client, and 3 staff files. LPA interviewed Staff. The FFA received 2 type B Deficiencies on today's visit, See LIC809D and Technical Violation. A copy of the report was provided at the conclusion of the inspection along with appeal rights.


summary: Facility Evaluation

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Narrative:
On the above date, Licensing Program Analyst (LPA), Brinae Pointer arrived at the Central Valley Community Resources THP+FC at Sylvan Ave, Suite A-5 for the purpose of conducting an unannounced Annual Required inspection. LPA met with Administrator, Arlene Figueroa-Morales. A walk through inspection of the facility was conducted. The Agency currently has 8THP+FC participants, employs one Social Worker and one full time Administrator/ Executive Director (ED), and CEO/Executive Director. A review of Guardian indicates that all facility staff associated and identified on the LIC500 have eligible clearance. There are 8 staff pending removal from the association to the facility. LPA discussed with administrator, the requirements for requesting exceptions for Social Worker Supervisors. LPA discussed with administrator the composition of the Emergency Disaster book which should include the fire drills, LIC610, client roster and updated NSP, which will be reviewed by LPA. LPA reviewed 3 staff files. The FFA received no Deficiencies or violations on today's visit. A copy of this report was provided at the conclusion of the inspection. LPA will return to the FFA on another date to complete this annual inspection.

met_with: Darlene Barber-Martinez, Executive Director & CEO


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Brinae Pointer arrived at the Central Valley Community Resources THP+FC at Sylvan Ave, Suite A-5 for the purpose of continuing an unannounced Annual Required inspection. LPA met with Administrator, Arlene Figueroa-Morales. LPA completed an interview with the facility Administrator. There were no clients on site. LPA received documents from the administrator including, client roster, exit interview documentation, board meeting minutes and certificate of compliance. LPA conducted a review of 5 client binders. LPA reviewed with administrator the composition and application of the Emergency Disaster book including quarterly in office fire drills, client roster and NSP for client files. These documents have been discussed and reviewed by LPA and as agreed, the administrator will send record of completed drills. The FFA received no Deficiencies on today's visit. At the conclusion of this inspection, administrator Figueroa-Morales has requested TSP services, and this LPA will submit the referral on behalf of this agency. A copy of the report was provided at the conclusion of the inspection along with appeal rights.


facility_name: CHILDREN'S HOPE THPP/THP+FC

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
The client felt threatened at first, but later agreed that it was a miscommunication and a one-time incident. The client was not able to retrieve their remaining belongings from the home immediately upon their move out but was granted access to the home to retrieve their belongings within a few days. A language barrier was observed by LPA, which confirmed the potential for misunderstandings between the client and the Resource parent, regarding their moving plans and desire to collect their belongings upon moving out. Resource Parents denied the allegations. Based on LPA's observations, interviews, and record reviews, although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove the violations did, or did not, occur. Therefore, the allegations are UNSUBSTANTIATED. A signed copy of this LIC-9099 report and the LIC-9099C were provided to the facility. An exit interview was conducted.

Investigation Findings:
13Licensing Program Analyst (LPA) Tina Thorn arrived unannounced at the facility on 02.09.24 for the purpose of delivering findings for the complaint investigation. LPA met with Julia JcCasland, Social Work Supervisor and Crystal Carter, CEO in training. LPA Thorn conducted the complaint investigation. LPA Lyta Vue opened the investigation with the facility on 11.22.23 and met with and interviewed Amelia Wakefield, Assistant Program Manager. LPA Thorn opened the investigation at the Resource Home on 11.21.23 and interviewed one Resource Parent and conducted a Health and Safety Inspection. During the course of the investigation, LPA conducted 10 additional confidential interviews. LPA reviewed records from the facility including Placement Roster, Agency social worker case notes, prior complaint history, Serious Incident Reports, and Needs and Service Plans for one client. Nine confidential interviews corroborated information regarding an incident involving a Transitional Housing client, moving to and from a Resource Home. Resource parents commented that the client would lose their placement if they left the home, based on information the Resource parent misheard from the agency. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Tina Thorn 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 25-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHICO - RESIDENTIAL, COHASSET RD., STE. FACILITY NAME: CHILDREN'S HOPE THPP/THP+FCFACILITY NUMBER: VISIT DATE: 02/09/2024

met_with: Julia McCasland, Social Work Supervisor and Crystal Carter, CEO in training


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Katherine Deaton conducted a case management investigation of the facility address listed above in compliance with COVID-19 precautions. The purpose of the case management was to review background clearance policies for prospective roommates of nonminor dependent THP participants. This report was discussed with Crystal Carter, Social Work Supervisor. On June 8, 2021, the LPA was notified by Ben Payne, Administrator (AD) that a new participant (P1 - see LIC Confidential Names list date 9/22/2021) informed the Agency Social Worker (ASW) that they lived with their prospective roommate (RM) while admitted to another Transitional Housing Placement Provider. AD stated that for this reason, ASW facilitated a living unit agreement with P1 and RM prior to receiving a response on RM's background clearance request. AD stated that they were informed RM requires an exception, and that this had been requested. On July 12, 2021, the LPA toured the facility which was clean, safe, and sanitary. On July 19, 2021, the LPA was informed by the facility that RM's background clearance exception was processed. Facility supervisors conducted staff training regarding background clearance policies and the protocol was submitted to the LPA. The LPA conferred with the Policy Department and confirmed on September 9, 2021, that Title Sections 80019(e) and 80019(g) did not apply, however Health and Safety Code Section did apply. These regulations have been included on the attached LIC809-C as reference. This form is continued from the attached LIC809. Regulatory Statute that applies: Health and Safety Code 1559.110(g)(2)(G) Any adult who is not a participant, including participants in Transitional Housing Program-Plus, as defined in subdivision(s) of Section 11400 of the Welfare and Institutions Code, and who resides with a participant shall obtain a criminal record clearance or exemption in accordance with Section 1522. Regulatory Statutes that do not apply: Title Section Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or (2) Request a transfer of a criminal record clearance as specified in Section 80019(f) or (3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 80019.1(r), unless, upon request for the transfer, the Department permits the individual to be employed, reside or be present at the facility. Title Section Criminal Record Clearance (g) Violation of Section 80019(e) will result in an immediate assessment of civil penalties of one hundred dollars ($100) per violation for a maximum of 5 days by the Department. (1) Subsequent violations within a twelve (12) month period will result in a civil penalty of one hundred dollars ($100) per violation per day for a maximum of thirty (30) days. (2) The Department may assess civil penalties for continued violations as permitted by Health and Safety Code Section 1548. No citations were issued throughout the course of this investigation.

met_with: Crystal Carter


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced visit was conducted by Licensing Program Analyst (LPA), Stefanie Whitlow, on 9/29/21 at 9: AM for annual inspection. During the visit, LPA met with supervisor, Crystal Carter, and toured the facility. The current license was available and posted prominently. A list of all current addresses and telephone numbers of all THPP participant living units and LIC 500 were provided. There was accessible telephone service and there was an office available that provided privacy for confidential interviews. LPA conducted six staff interviews. All staff and participant records are maintained electronically on a computer program. General clerical staff members assisted LPA with navigating the program to review records, and LPA was able to complete review for one participant, but this was time consuming. At 3: PM, LPA spoke supervisor, Crystal Carter, and requested that a staff member familiar with the system assist LPA when LPA returns to complete the inspection 9/30/21 at 1: PM, which she said she could accommodate. Exit interview was completed, LIC 809 signed, and sent electronically.


summary: Facility Evaluation

raw_content:
Narrative:
An announced visit was conducted by Licensing Program Analyst (LPA), Stefanie Whitlow, on 9/30/21 at 1: PM fo continuation ofr annual inspection. During the visit, LPA met with supervisor, Crystal Carter, and reviewed records of ten participants. A technical advisory is being given, but no citations. The Needs and Services Plans of three out of ten participants were not signed by the placing agency, as required, but this does not pose an immediate health and safety risk. LPA also began reviewing staff records, but was unable to complete. LPA will return to facility on 10/1/21 to continue annual inspection. An exit interview was conducted with supervisor, Crystal Carter, who signed LIC 809, and a copy was emailed to the licensee.


summary: Facility Evaluation

raw_content:
Narrative:
An announced visit was conducted by Licensing Program Analyst (LPA), Stefanie Whitlow, on 10/01/21 at 9: AM for continuation of annual inspection. During the visit, LPA met with supervisor, Crystal Carter. Records of ten staff members, the Plan of Operation, and Disaster Preparedness Plans were reviewed. There were no noted deficiencies, although LPA gave a technical advisory. No citations were given. The staff record files contained all required documents, but were not compartmentalized into sections. LPA advised licensee to make more effective provisions for future record review. An exit interview was conducted with supervisor, Crystal Carter, who signed LIC 809, and a copy was emailed to the licensee.