raw_content:
Investigation Findings:
13On December 28, 2023, Licensing Program Analyst (LPA) C. White arrived at Wayfinder Temporary Shelter Care Facility (TSCF) for the purpose of delivering findings for the above allegations. LPA met with Administrator, Veta Talton. During this investigation, LPA conducted confidential interviews, gathered documentation, reviewed records and reports. Based on information obtained and due to inconsistent statements, there was insufficient corroborating evidence to support the allegations: staff drinking alcohol while caring the supervising minors in care; staff transported minors while under the influence of alcohol; facility staff members made inappropriate comments to minor; facility staff member inappropriately touched minor. Therefore, the allegations are found to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violations did or did not occur. There were no deficiencies cited. An exit interview was completed, and a copy of this report was left with the Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Charmetha White LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

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

met_with: Veta Talton - Administrator


state: CA

facility_name: WAYFINDER FAMILY SERVICES - TSCF

summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13On October 3, 2024, Licensing Program Analyst (LPA) C. White arrived at Wayfinder Temporary Shelter Care Facility (TSCF) for the purpose of delivering findings for the above allegation. LPA met with Administrator, Veta Talton. During the course of this investigation, LPA conducted confidential interviews, gathered documentation, and reviewed records. Staff denied the allegations and stated the gym located on the grounds of Wayfinder is not operated by the TSCF. Staff stated the facility has not been without hot water, that 8 out of 17 bathrooms did not have access to hot water on two separate days due to maintenance repairs. Based on information obtained, the allegations are found to be unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violations did or did not occur. There were no deficiencies cited. An exit interview was completed, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Bernice Karnsrithong LICENSING EVALUATOR NAME: Charmetha White LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

report_type: Complaint Investigation

met_with: Administrator - Veta Talton

complaint_status: unsubstantiated


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Due to lack of evidence obtained during the investigation, LPA determines that the allegations are Unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that a violation occurred. There are no deficiencies cited at this time. An exit interview was conducted, and a copy of this report was left with Administrator, Veta Talton.

Investigation Findings:
13On April 15, 2025, at 9:30AM, Licensing Program Analyst (LPA), Rosslyn Gray made an unannounced visit to conclude the investigation. Prior to entering the facility LPA Gray conducted a health and safety risk assessment. During the investigation, LPA Gray interviewed all available relevant parties and gathered pertinent information in reference to the allegations. The Licensee denied the allegation. Based on confidential interviews and review of documentary evidence, there is no evidence or witnesses to support allegations. Statements indicated that C1 plan indicated that additional food should be provided and to call for medical assistance as needed. Statements indicated that during incident C1 expressed that they were not feeling well. C1 was provided apple juice and apple sauce, and staff called for medical assistance. Statements indicated that foods were purchased for C1's condition and made accessible for consumption when needed. Statements indicated that C1 was not denied access to food at time of incident. Statements indicated that children in care are provided breakfast, lunch, dinner, snacks, and can ask for additional food. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Rosslyn Y. Gray LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: WAYFINDER FAMILY SERVICES - TSCFFACILITY NUMBER: VISIT DATE: 04/15/2025

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

met_with: Administrator/Veta Talton


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Due to the evidence obtained during the investigation, LPA determined that the allegation is substantiated; means that based on the preponderance of the evidence meaning that it is more likely than not, the allegation of Neglect/Lack of Supervision are substantiated. The facility is cited for violation of California Code of Regulations, Title Division Six, regulation Responsibility for Providing Care and Supervision 80078 (a). Staff did not provide care and supervision that met the needs of clients in care. An exit interview was conducted, and a copy of this report and Appeal Rights were left with the Administrator, Veta Talton.

Investigation Findings:
13On April 14, 2025, at 9:30AM, Licensing Program Analyst (LPA), Rosslyn Gray made an unannounced visit to conclude the complaint investigation. Prior to entering the facility LPA Gray conducted a health and safety risk assessment. During the investigation, LPA Gray interviewed all available parties and reviewed documentary evidence. Statements and review of documentary evidence were consistent. Confidential statements and an internal investigation indicated that staff refused to provide care services to minors. Statements indicated that clients arrived at the facility with medical issues that required medical attention and with instruction on how to treat their medical issues. Documentary evidence indicated that staff were issued final written warnings that outlined their role expectations and that their refusal to provide care and supervision to clients was unacceptable and they were instructed to adhere to the corrective actions. Documentary evidence indicated that staff are no longer employed due to resigning from positions. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Rosslyn Y. Gray LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: WAYFINDER FAMILY SERVICES - TSCFFACILITY NUMBER: VISIT DATE: 04/15/2025

met_with: Administrator, Veta Talton.

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Investigation Findings:
13Licensing Program Analyst Connie Jones-Steward investigated the above allegations. LPA interviewed the program director, the housing director , the nurses assigned to the client and the youth counselors assigned to child . LPA attempted on three occasions to reach the client's social worker but was unsuccessful. LPA also reviewed the email chain between Wayfinders and the Department of Children & Family services. Wayfinder staff repeatedly requested assistance from DCFS because they were not properly trained to feed Client #1 or maintain her feeding tube. The emails also indicated that the client had insufficient feeding supplies with her when she arrived on site. LPA reviewed the daily observation log for Client #1 and noted that although she was in the facility for three days, she was only given one shower and on the first day she was not fed from 3: AM until 1: PM while staff waited on authorization from nursing. The shift notes indicate that insufficient feeding supplies hampered efforts to feed C1 properly and on the day of discharge she was not fed due to a missing g-tube connection. Based on the information that was obtained, the allegations are resolved as "substantiated" meaning that the preponderance of evidence standard has been met. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: WAYFINDER FAMILY SERVICES - TSCFFACILITY NUMBER: 198209635

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

met_with: Teresa Marroquin, Shift Leader


summary: Facility Evaluation

raw_content:
Narrative:
On July 22, 2021 at 12: PM, Licensing Program Analyst (LPA) Charmetha White made an announced visit at Wayfinder TSCF for the purpose of a Case Management-Licensee Initiated Inspection to increase the capacity. LPA met with the Chief Program Officer, Veronica Arteaga, TSCF Director, Kristal Audoma, Associate VP of Residential Clinical Services, Ani Sargsyan, and the Director of Mental Health, Kaela Stambor and was granted access to the facility. The facility is currently licensed to provide care for 26 children, ages 0-17 years old, ten (10) children may be infants ages 0-2 years, six (6) may be non-ambulatory. The facility is requesting to increase the total capacity to 38 to provide care for 26 children, ages 0-17 years old, seven (7) infants ages 0-2 years, as well as Non-Minor Dependents ages eighteen (18) through twenty-one (21). The current census is 16. A tour of the STRTP and TSCF buildings began at 12: PM and LPA observed the following: STRTP Building: Is a two-story building which has a small kitchen, an open living/dining room, a laundry room, a staff lounge, 2 staff offices, a nurse's center, a therapy room, a recreation/activity room, and a computer room. This building will house clients ages 0-17 and it is currently not occupied. The first floor will be utilized for children ages 0-12. This floor has 2 infant bedrooms equipped with 3 cribs each, 1 mom and baby bedroom equipped with a twin bed and a crib, 2 toddler bedrooms equipped with 2 toddler beds including rails in each room, and 4 bedrooms are designated for young children, 3 room are double occupancy and equipped with 2 twin beds and 1 room is single occupancy and equipped with one twin bed. All bedrooms have adequate closet space and lighting. There are bathrooms located inside of each of the bedrooms and 6 additional bathrooms located throughout the building. The second floor will be utilized for children ages 13-17. This floor has 9 bedrooms, 9 bathrooms and a room that is for storage. There was adequate drawer and closet space. DCFS Co-locator staff office. LPA observed this building to be equipped with badge readers on the elevator doors and stairwell doors that open between floors. All exit doors open freely. Report continued on LIC809C TSCF Building: Is a two-story building which has a kitchen area, an open living/dining room, 2 staff offices, DCFS Co-locator staff office, a laundry room and a storage room. This building will be used to house the requested Non-Minor Dependents ages 18-21 and it is currently occupied by clients ages 0-17. The first floor has 6 bedrooms and the second floor has 5 bedrooms, all bedrooms have attached bathrooms, adequate closet space, and windows that open freely. There are 3 additional bathrooms located throughout the building. There are no weapons in the facility. The swimming pool area is locked and meets licensing requirements. All prescribed medications are centrally stored in locked in cabinets or in a locked refrigerator located in the Nursing Center and medications are only accessible to employees supervising stored medications. Cleaning supplies are kept locked and made inaccessible to clients. The facility is equipped with a fire alarm system, smoke alarms, and carbon monoxide detectors. All fire extinguishers are charged. There facility has working telephones for client's personal use. All exits are free and clear from hazards. The following documents were previously submitted: a new LIC 200, a new Facility Sketch (LIC 999), a LIC C (Emergency Disaster Plan), and a Board Resolution approving the capacity increase. Exit interview conducted and a copy of this report was left with the Chief Program Officer.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Chief Program Officer - Veronica Arteaga


summary: Facility Evaluation

raw_content:
Narrative:
On August 18, 2021 at 12: PM, Licensing Program Analyst (LPA) Charmetha White conducted a Case Management - Incident inspection visit at the above location for the purpose of conducting a follow up investigation. LPA spoke to Kaela Stambor - TSC Mental Health Director to further discuss Special Incident Report #768862 regarding a possible Neglect/Lack of Supervision Violation. The Incident Report was submitted to Community Care Licensing (CCL) on August 9, 2021. The incident occurred on 08/08/2021. Client #1 returned from AWOL at 11: PM and reported that an unknown male swung a knife at him and grazed his forearm and stomach area. Staff observed Client to have two linear superficial cuts, one on the left forearm and one on the right side of stomach. Staff cleaned the cuts however, the client refused to go to the doctor. Staff contacted the Child Protective Hotline and was issued 5231-1896-9045719. . During this visit LPA spoke to staff and obtained statements. LPA was also informed that Client #1 is no longer in placement at the facility. Based on the information obtained there was insufficient information to determine that a Neglect/Lack of Supervision Violation occurred at this time. Further information is needed. An exit interview was conducted, and a copy of this report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On January 31, 2023 at 8: AM, Licensing Program Analyst (LPA) Charmetha White made an unannounced visit at Wayfinder TSCF for the purpose of a Year Required Visit. LPA met with Administrator, Veta Talton and was granted access to the facility. The facility is currently licensed to provide care Temporary Shelter Care Services up to ten (10) days for 26 children, male and female ages 0-17 years old, seven (7) children may be infants ages 0-2 years, ambulatory only. The facility also licensed to provide services to non-minor dependents pursuant to W & I code 16501.1(C)(1). The current census is 4. LPA observed the following: The facility is a two story building located in a residential area. Each floor contains a small kitchen, an open living/dining room, a laundry room, and 2 staffing offices. The first floor has two (2) infant bedrooms each equipped with 3 cribs; one (1) mom and baby bedroom equipped with a twin bed and a crib; three (3) double occupancy bedrooms each equipped with two twin beds; one (1) single occupancy bedroom equipped with one twin bed; a CSPS/Case Manager office; and a staff's lounge. The second floor has six (6) bedrooms each equipped with two twin beds; a recreation/activity room; a computer room; a therapist office; a DCFS co-locator office; and a storage room. All bedrooms have adequate closet space and lighting. There are bathrooms located inside of each of the bedrooms and 6 additional bathrooms located throughout the building. LPA observed the building to be equipped with badge readers for the elevator and stairwell doors that open between floors. Additionally, the facility has a nursing center, a gym, an a locked/gated swimming pool, which meets licensing requirements, on the premises. Report continued on LIC 809C LPA conducted a physical plant inspection and found the facility to be clean, safe, sanitary and in good repair. LPA observed the facility's main kitchen to contain one week supply of non-perishable foods and two days supply of perishable foods, including nutritious snacks. All prescribed medications are locked and centrally stored in the Nursing Center and made accessible only to employees supervising stored medications. The first was checked and found to be complete. The hot water temperature is within 105 -120 degree Fahrenheit. The facility is equipped with a hardwired fire alarm system, and there are combination smoke alarm/carbon monoxide detectors in each room, all of which were operational at the time of this inspection. All fire extinguishers are charged. All trash cans have tight-fitting lids. All exits are free of hazards and all doors open freely. Cleaning supplies are kept locked and made inaccessible to clients. There are no weapons in the facility. LPA observed the facility to have adequate linen supply and hygiene products. There was ample seating in the living/dining room area. The facility has an operable telephone on the premises. Meals are prepared in the main kitchen during the week and prepared on the premises during the weekends. Activities available include toddler toys, reading books, games, etc. The facility operates within license conditions and limitations including capacity limitations. LPA discussed and advised the Licensee to ensure the following: Children are supported and encouraged to participate in extracurricular activities. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. All posting requirements and Emergency Plan were met. The Program has a total of (seventeen) staff and personnel files are located in the administration building. LPA will return on a later date to review staff records. There were no deficiencies noted on this date. Exit interview was completed and a copy of this report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On January 4, 2024, Licensing Program Analyst (LPA) Charmetha White arrived at Wayfinder TSCF for the purpose of a Case Management-Licensee Initiated Inspection to decrease the capacity. LPA met with the Administrator, Veta Talton and was granted access to the facility. The facility is currently licensed to provide care for 38 clients, ages 0-17 years old, seven (7) children may be infants ages 0-2 years, ambulatory only, as well as Non-Minor Dependents ages eighteen (18) through twenty-one (21). This facility is requesting to decrease the total capacity to 20 to provide care for 20 children, ages 0-17 years old, five (5) children may be infants ages 0-2 years, ambulatory only. The current census is four (4). During the tour of the TSCF building LPA observed the following: TSCF Building: Is a two-story building located in a residential neighborhood. The first-floor houses clients ages 0-12 and contains the following: a small kitchen in the middle of the room, an open living/dining room area, a staff lounge, the Facility Manager's office, the Assistant Director's office, a CSPS/Campus Security office, therapy room, a laundry room, nine (9) bedrooms, and multiple bathrooms. Bedrooms #1 is an infant bedroom equipped with three (3) cribs, three (3) portable play yards, and one (1) changing table. Bedroom #2 is an infant bedroom equipped with two (2) cribs, two (2) baby swings, and one (1) changing table. Bedroom # 3 is a mom and baby room equipped with two (2) cribs, one (1) twin bed, and 1 changing table. Bedrooms # 4 through #8 are double occupancy rooms and each room has two (2) twin beds. Bedroom #9 is a single occupancy room and has one (1) twin bed. All bedrooms contain a bathroom, have adequate drawers, closet space, and lighting. Report continued on LIC 809C (Page 1 of 2) The second-floor houses clients 13-17 and contains the following: a small kitchen in the middle of the room, an open living/dining room area, the Administrator's office, the Assistant Administrator's office, the Program Assistance Office, the Mental Health Teams office, the DCFS co-locator's office, a therapy room, an activity storage room, a laundry room, a game room, six (6) bedrooms, and multiple bathrooms. Bedrooms #10 through #16 are double occupancy rooms and each room has two (2) twin beds. All bedrooms contain a bathroom, have adequate drawers, closet space, and lighting. LPA observed this building to be equipped with badge readers on the elevator doors and stairwell doors that open between floors. All exit doors open freely. Smoke detectors and carbon monoxide alarm were tested and were in working condition. Additionally, the facility has a nursing center, a gym, an a locked/gated swimming pool on the premises, which meets licensing requirements. Licensee previously provided the following documents: a new LIC 200, $25.00 capacity decrease fee, corporate resolution, emergency evacuation plan. Based on observations from today's inspection the following is required before the capacity can be decreased. A total of 2 cribs will need to be taken down and removed. A total of 9 twin beds will need to be taken down and removed. A new facility sketch will need to be submitted. A Fire Clearance. There were no deficiencies noted on this date. Exit interview was completed and a copy of this report was left at the facility. (Page 2 of 2).


summary: Facility Evaluation

raw_content:
Narrative:
On February 13, 2024, Licensing Program Analyst (LPA) Charmetha White arrived at Wayfinder TSCF for the purpose of a Case Management-Licensee Initiated Inspection to decrease the capacity. LPA met with the Administrator, Veta Talton and was granted access to the facility. The facility is currently licensed to provide care for 38 clients. This facility is requesting to decrease the total capacity to provide care for 20 children, ages 0-17 years old, five (5) children may be infants ages 0-2 years, ambulatory only. The current census is two (2). During the tour of the TSCF building LPA observed the following: TSCF Building: Is a two-story building located in a residential neighborhood. The first-floor houses clients ages 0-12 and contains the following: a small kitchen in the middle of the room, an open living/dining room area, a staff lounge, the Facility Manager's office, the Assistant Director's office, a CSPS/Campus Security office, therapy room, a laundry room, nine (9) bedrooms, and multiple bathrooms. Bedrooms #1 is an infant bedroom equipped with two (2) cribs, two (2) portable play yards, and one (1) changing table. Bedroom #2 is an infant bedroom equipped with two (2) cribs, two (2) baby swings, and one (1) changing table. Bedroom # 3 is a mom and baby room equipped with one (1) crib, one (1) twin bed, and 1 changing table. Bedrooms # 4 through #6 are double occupancy rooms and each room has two (2) twin beds. Bedrooms #7 and #8 are single occupancy rooms and each room has one (1) twin bed. All bedrooms contain a bathroom, have adequate drawers, closet space, lighting, and windows. Room #9 will be used as a playroom and LPA observed the room to have a flat screen television mounted to the all. There was no furniture in the room. Report continued on LIC 809C The second-floor houses clients 13-17 and contains the following: a small kitchen in the middle of the room, an open living/dining room area, the Administrator's office, the Assistant Administrator's office, the Program Assistance Office, the Mental Health Teams office, the DCFS co-locator's office, a therapy room, an activity storage room, a laundry room, a game room, six (6) bedrooms, and multiple bathrooms. Bedrooms #10 and #11 are single occupancy rooms and each has one (1) twin bed. Bedrooms #13 and #14 are double occupancy rooms and each room has two (2) twin beds. All bedrooms contain a bathroom, have adequate drawers, closet space, lighting, and windows. Room #12 will be used for storage. LPA observed the room to have one (1) desk and one (1) chair. Room #15 will be used for storage. LPA observed the room to contain stacked mattresses, extra desks, chairs, and a broken-down crib. Room #16 will be used as an activity room. LPA observed the room to have shelves stacked with games and toys. LPA observed the building to be equipped with badge readers on the elevator doors and the stairwell doors that open between floors. Al exit doors open freely. There are no weapons in the facility. Additionally, the facility has a gym on the premises and a swimming pool area which remains locked and meets licensing requirements. There is a Nursing Center, all prescribed medications are centrally stored in locked cabinets or in a locked refrigerator located in the Nursing Center. All medications are only accessible to employees supervising stored medications. Cleaning supplies are kept locked and made inaccessible to clients. The facility is equipped with a fire alarm system, smoke alarms, and carbon monoxide detectors. All fire extinguishers are charged. There facility has working telephones for client's personal use. All exits are free and clear from hazards. Licensee previously provided the following documents: a new LIC 200, $25.00 capacity decrease fee, corporate resolution, emergency evacuation plan. Based on observations from today's inspection the following is required before the capacity can be decreased. A Fire Clearance. There were no deficiencies noted on this date. Exit interview was completed and a copy of this report was left with the Facility Administrator.

met_with: Veta Talton - Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On October 29, 2025, Licensing Program Analyst (LPA) C. White made an unannounced visit to the above facility, for the purpose of conducting a Case Management inspection to address concerns regarding Immediate Exclusion Order, AO Johnson BC #7402027. LPA met with Interim Administrator, Lakesha Buchanan, who provided access to the facility. An order of immediate exclusion was issued by the CDSS office on October 16, 2025, stating that, staff (S1) must immediately be removed from any contact with clients and not be physically present in any agency or home licensed/approved by the Department. LPA received a Personnel Report (LIC 500), which did not show S1 associated with the facility. LPA checked the Guardian Website, which list S1 was associated on 10/02/2024, separated on 10/02/2024, and is no longer associated with this facility. Additionally, LPA received a letter dated January 30, 2025, addressed to S1, notifying S1 that the offer of employment which was extended on 10/01/2024 was withdrawn due to unsuccessful clearance of the background screening. Based on evidence obtained, LPA C. White has verified the facility is in compliance with the exclusion order as S1 is not present or employed with the facility. There are no deficiencies to be cited at this time. Exit Interview conducted, and a copy of this report was left at the facility.

met_with: Lakesha Buchanan - Interim Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On December 16, 2025, Licensing Program Analyst (LPA) C. White made an unannounced visit to the above facility, for the purpose of conducting a Case Management inspection to determine if Elizabeth Diaz (S1) was employed at the facility. LPA met with Interim Administrator, Lakesha Buchanan, who provided access to the facility. Per Decision and Order (CDSS #7925247011) effective December 11, 2025, Elizabeth Diaz is prohibited from employment in, presence in, and contact with clients of, any facility licensed by the Department, certified or approved by a licensed foster family agency, or any resource family home, and from holding the position of member of the board of directors, executive director, or officer of the licensee of any facility licensed by the Department. LPA received a Personnel Report (LIC 500), which did not show S1 associated with the facility. LPA checked the Guardian Website, and was unable to locate S1. Additionally, the Interim Administrator verified that S1 was never employed at the facility. Based on evidence obtained, LPA C. White confirmed the facility is in compliance with the Decision and Order as S1 is not present or employed with the facility. A Review of Staff Records Showed That All Adults Providing Care and Supervision to Clients Have a Criminal Record Clearance and Child Abuse Clearance. There were no deficiencies cited. An exit interview was conducted.


summary: Facility Evaluation

raw_content:
Narrative:
On July 25, 2025, Licensing Program Analysts (LPA), C, White made an unannounced visit to Wayfinder Family Services - TSCF for the purpose of conducting a Case Management Inspection, as the Department was made aware an unapproved Director/Administrator Change. LPA met with Staff, Steven Frausto. During today's inspection, LPA was informed the previous Director/Administrator (Veta Talton) is no longer overseeing the program. Staff member, Steven Frausto stated he was promoted to the new Director/Administrator of the TSCF effective 06/01/2025. LPA spoke with the Vice President, Clinical and Housing Services stated the previous Director/Administrator (Veta Talton) is being used as a backup administrator at this time and that Staff member, (Steven Frausto) is in the process of obtaining the required Group Home Administrator Certificate. Additionally, LPA confirmed with Staff member, (Steven Frausto) that he does not currently hold a Group Home Administrator Certificate. LPA informed Staff member, Steven Frausto, that the facility is being cited for failure to have a certified administrator employed. The following deficiency is being cited for violating California Code of Regulations Title 22, Division Regulation 84064(b) Administrator Qualification and Duties. (see page D) Exit interview completed, appeal rights issued, and a copy of this report was emailed to Staff member, Steven Frausto.

met_with: Staff Member - Steven Frausto


facility_name: 3R'S GROUP HOME, INC-THP+FC PROGRAM

raw_content:
Investigation Findings:
13On 11/22/23, Licensing Program Analyst (LPA) Lisa Slusher conducted an unannounced complaint investigation for the above facility. Met by program Director Fatimah Rodriguez. Confidential Interviews conducted and information and documents obtained. Based on confidential interviews conducted and information obtained, there are conflicts. Based on the above, the complaint is Unsubstantiated. There are no deficiencies to be cited on this date. A copy of this report is given on this date to the Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lisa Slusher LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

met_with: Fatimah Rodriguez


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst Lisa Slusher and LPA Briana Placencia travelled to the 3R's THP + NMD office in Fresno CA. LPA was met by Administrator Fatimah Rodrigez , for the purpose of a scheduled pre-licensing inspection for a change of location for a THP + NMD. A general overview of their program and a tour of the facility was provided. This facility has a reception area, waiting area, and office space for staff. Observed fixtures and furniture, equipment and supplies necessary for this operation. Also observed locked cabinets for client and staff files in order to ensure confidentiality. Discussed daily ongoing functions including incident reports. There is ample confidential space for meeting with clients on an as needed basis. The agency employs one administrator, one social worker supervisor, two social workers and four case managers. All files are to be moved from location currently licensed at N. Van Ness Ave., Fresno. All facility staff fingerprints will transfer to the license number listed on this report following licensure. The agency intends to submit an application for a capacity change. The agency will submit a new LIC 200, board resolution and processing fee. The above licensee meets the requirements to be licensed as a THP+NMD in Fresno County county, to be extended to other counties within a two hour driving distance with program statement update. On a quarterly basis, facility is to submit a roster of THP+NMD clients that includes client names, dates of birth, county worker and current address of placement.

visit_type: Prelicensing


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, LPA Lisa Slusher conducts a post licensing visit at the above licensed facility. Met by Administrator Fatimah Rodriguez. Facility physical plant inspected. Agency has adequate space for Social Work activities and confidential meeting space with youth. Files are appropriately secured. Discussed current operations, plans for the facility and incident reporting. Received updated LIC 500. Recejved roster of clients, certified THP+FC units. Discussed agency activities to secure housing units. Reviewed client and personnel files. Discussed updates and improvements to needs and services plans. No deficiencies noted on this date.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/01/2021, an unannounced annual inspection is conducted by Licensing Program Analyst (LPA) T. Met at the THPP office by Program Manager Fatimah Rodriguez . Currently the program is staffed by the Administrator, a Program Manager, a Supervising Social worker, two Case Managers and 6 independent Living Support Staff. At 10:00AM, participant files and staffing files reviewed. All staff meet appropriate regulatory requirements. Licensee provided updated client roster and personnel report. There are no deficiencies to be cited on this date. A copy of this report is left with the Program Manager A Technical Violation is issued on this date for Reporting Requirements. Discussed updated staffing for the facility and potential changes. .

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
On this date a case management inspection is conducted by LPA (Licensing Program Analyst) Lisa Slusher. Met at the office by Program Manager Fatimah Rodriguez. Discussed Emancipation accounts for youth and the distribution of funds to youth who exit the program. Agency will ensure that process is consistent with what is noted in the program statement or will submit an update for the program statement Agency to submit an updated LIC 400 and ensure that the department has the original bond. Discussed potential capacity increase. Facility to submit the following: 1. LIC 200 2. Board Resolution approving increase 3. LIC 500 including staff to be added in accordance with census and regulatory ratios 4. $25 processing fee


summary: Facility Evaluation

raw_content:
Narrative:
On this date, a case management inspection is conducted by LPA (Licensing Program Analyst) LIsa Slusher. Met at the facility by Fatimah Rodriguez. Discussed incident report dated 10/31/23. LPA conducted review of file for S1 and C1 (See LIC 811 dated 11/6/23). Further investigation into this incident will be conducted.


facility_name: 3R'S THP+FC

summary: Facility Evaluation

raw_content:
Narrative:
On this date an unannounced annual inspection is conducted at the THP+FC office with Program Manager Fatimah Rodriguez. LPA inspected both the participant's files and staff files. Facility provided the following forms upon inspection: LIC LIC LIC 610C Roster of Participants There were no deficiencies cited during this inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On this date a case management inspection is completed by LPA Lisa Slusher. Facility is in the process of changing the administrator and appropriate documentation will be submitted within 10 days of that change. LPA to follow up on capacity increase dates.


summary: Facility Evaluation

raw_content:
Narrative:
On this date 2/23/22 at 1:30 pm Licensing Program Analyst (LPA) Lisa Slusher travelled to the facility to conduct an annual inspection. Prior to this inspection a pre-inspection Covid screening was conducted. Met with Administrator Fatimah Rodriguez.. A physical plant inspection was completed and included the following checks: client and staff files are kept in locked filing cabinets, and are printouts from an electronic filing system. Facility has adequate confidential meeting space and space for Social Workers to complete job duties. A review of their staff files on this date indicate that all facility staff have received child abuse index clearances and fingerprint clearances. Agency staff meet requirements of respective job descriptions. Agency Employs one Administrator, One Social Worker Supervisor/Social Worker, one Case Manager. Agency is in the process of onboarding an additional Case Manager. Employee and THPP Participant files reviewed. THPP Participant files were transferred from the Licensee's Tracy office. An exit interview was conducted with the Administrator.


facility_name: 3RS THP+FC

raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA), Lidia Tinoco conducted an unannounced visit to the 3R's THP+FC in order to deliver the findings of the above allegations and met Housing Supervisor, Kesha Ingram. On June 19, 2024, the above allegations were referred to Community Care Licensing for investigation. The investigation included an inspection of the Facility, confidential interviews, and review of records. Based on the investigation conducted the department found that there was conflicting information regarding these issues. Although the allegations may have happened of are valid, there is not a preponderance of evidence to prove the allegations occurred. Therefore, the allegations are Unsubstantiated at this time. A copy of this report was provided at the conclusion of the inspection along with appeal rights. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Kesha Ingram


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst Lisa Slusher travelled to the 3R's THP + NMD office in Fresno CA. LPA was met by Administrator Fatimah Rodrigez , for the purpose of a scheduled pre-licensing inspection for a change of location for a THP + NMD. A general overview of their program and a tour of the facility was provided. This facility has a reception area, waiting area, and office space for staff. Observed fixtures and furniture, equipment and supplies necessary for this operation. Also observed locked cabinets for client and staff files in order to ensure confidentiality. Discussed daily ongoing functions including incident reports. There is ample confidential space for meeting with clients on an as needed basis. The agency employs one administrator, one social worker supervisor, two social workers three case managers and ILSS workers. All files are to be moved from location currently licensed at W. Shields Ave. All facility staff fingerprints will transfer to the license number listed on this report following licensure. The above licensee meets the requirements to be licensed as a THP+NMD in Fresno County county, with the ability to place participants within a two hour radius. On a quarterly basis, facility is to submit a roster of THP+NMD clients that includes client names, dates of birth, county worker and current address of placement.


summary: Facility Evaluation

raw_content:
Narrative:
On this date, an unannounced case management inspection is conducted by LPA (Licensing Program Analyst) Lisa Slusher. Met with Shatari Sykes. LPA spoke with Administrator Fatimah Rodriguez by phone. The purpose of this inspection is to follow up on an incident report received 3/25/24 which occurred on 3/11/24. A technical violation is issued on this date for reporting requirements for failure to report the incident within prescribed time frames. Additionally, LPA discussed provider issues with Guardian and completed an employee transfer while at the facility.

met_with: Shatari Sykes


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analysts (LPAs), Lidia Tinoco and Sonia Sanchez arrived at 3R's THP+ FC for the purpose of conducting an unannounced Post Licensing inspection. LPA met with Program Administrator, Shatari Sykes and Director, Fatimah Rodriguez and inspected the facility, inside and out. The facility has a written emergency disaster plan. A fire extinguisher is properly charged. Facility has cameras in common areas of the facility. The facility employs Administrator, Social Worker Supervisor, Social Worker, Case Managers, Administrative Assistants and Office Manager. Five records of personnel/staff members were reviewed to ensure staff meet regulatory requirements. Personnel Files are maintained on-site. The assigned Licensing Program Analyst will work with the facility regarding fingerprint clearances and Guardian. Five records of clients were reviewed. Staff interview was conducted. Two type B deficiencies are being cited, see LIC809D. Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were provided at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at the 3R's and met with Administrator, Fatimah Rodriguez. At the time of the visit Administrator provided LPA Tinoco emails that were sent out on July 1, 2024 that were not delivered to LPA due to an error in the email. On this date, Administrator provided LPA the POC documents requested. The POC for deficiencies issued on 6/24/24 were cleared on today's date. The POC Clearance Letter was provided to Administrator. No deficiencies were cited on this date. A copy of this report was provided at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst Lisa Slusher arrived at 3R's THP+ FC for the purpose of conducting an unannounced Annual inspection. LPA met with staff person Nuryah Williams and spoke with Administrator Fatimah Rodriguez by telephone who arrived a short time later, and inspected the facility, inside and out. The facility has a written emergency disaster plan. A fire extinguisher is properly charged. Facility has cameras in common areas of the facility. Certificates of compliance were observed for all remote/scattered sites where participants are placed. The facility employs Administrator, Social Worker Supervisor, Social Worker, Case Managers, Office Manager and Independent Living Support staff. Six records of personnel/staff members were reviewed to ensure staff meet regulatory requirements. Personnel Files are maintained on-site. All staff are appropriately fingerprint cleared and associated. Six Records of clients were reviewed. Staff interviews were conducted. No deficiencies noted in areas observed A copy of this report and appeal rights were provided at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, LPAs (Licensing Program Analysts) Lisa Slusher conducted a case management inspection at the above agency. The purpose of this inspection is to address an incident report dated 12/21/24. LPA discussed the incident report with Administrator Fatimah Rodriguez. Facility has an appropriate plan in place and recently participated in a child and family team meeting with the NMD. See LIC 811 for confidential names No deficiencies noted at this time.


summary: Facility Evaluation

raw_content:
Narrative:
On this date, LPA (Licensing Program Analyst) Lisa Slusher conducted a case management inspection at the above facility. The purpose of this inspection is to re-capture signatures which did not save during a previous inspection. LPA also received additional information regarding an incident report during inspection. No deficiencies noted in areas observed.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Sonia Sanchez arrived at 3R's THP+ FC for the purpose of conducting an unannounced Annual inspection. LPA met with Program Administrator Fatimah Rodriguez, and inspected the facility. The facility has a written emergency disaster plan. Two fire extinguisher's that were purchased on January 8, 2026 confirmed by receipt and observation of extinguishers. Facility has cameras in common areas of the facility. Certificates of compliance were observed for all remote/scattered sites where participants are placed. The facility employs Administrators, Social Worker Supervisor, Program Compliance Admin, Housing Specialist, Case Managers, 1 social worker, Independent Living Support staff, Office Manager and Admin Assistants. Five records of personnel/staff members were reviewed to ensure staff meet regulatory requirements. Personnel Files are maintained on-site. All staff are appropriately fingerprint cleared and associated. Five records of clients were reviewed. Staff interviews were conducted. No deficiencies noted in areas observed. A copy of this report was discussed and provided to Ms.Rodriguez at the conclusion of the inspection.

met_with: Fatima


summary: Facility Evaluation


facility_name: A NEW BEGINNING FOR ME

summary: Facility Evaluation

raw_content:
Narrative:
On February 4, 2025, at AM, a Component II Office Visit was held to discuss the application received for A New Beginning For Me located at 43545 17th Street W. Unit Lancaster, CA 93534. Attending Component II were the following individuals:Princess Wesley, Applicant, Erika Butler, Licensing Program Analyst, and JoAunne Griffin, Licensing Program Manager. The purpose of this Component II meeting was to review and discuss the incomplete application and Program Statement and to resolve any outstanding concerns that may have existed. The following incomplete application forms were discussed at the meeting: 1. Affidavit Regarding Client/Resident Cash Resources (LIC 400) 2. Budget Information (LIC 420) 3. Personnel Report (LIC 500) 4, Personnel Record (LIC 501) 5. Health Screening Report (LIC 503) 6. Out of State Criminal Record Statement (LIC 508D) 7. Criminal Background Clearance Transfer Request (LIC 9182) Continued on C 8. Copy of your Driver License Program Statement Licensee needs to revise the Program Statement and place each section under the tab sections. The Applicant was advised of the following revision and/or corrections needed to the application and/or Program Statement: Revisions are due by March 4, 2025. Email revisions to erika.butler@dss.ca.gov. A copy of this report was provided to the Applicant, Princess Wesley.

met_with: Princess Wesley


summary: Facility Evaluation

raw_content:
Narrative:
On March 27, 2025, at AM, Licensing Program Analyst (LPA) Cheri Wilkerson, and Licensing Program Manager (LPM) JoAunne Griffin arrived at A New Beginning Transitional Housing Placement Program (THPP) administrative office located at 43545 17th St. W # Lancaster, CA 93534 for the purpose of conducting a Pre-Licensing inspection. LPA and LPM conducted a walk-through of the administrative office with Princess Wesley, Administrator. A health and safety assessment was conducted. LPA and LPM observed the office suite to be in an office building on the second floor. The office suite consists of reception area, three offices spaces, kitchen, and bathroom. Office Space 1: will be utilized as a career/trade space for clients. Office Space 2: will be utilized for confidential interviews. Space is equipped with chair, desk, and cabinet space. Office Space 3: will be utilized as administrator office. Space is equipped with chair, desk, laptop, and monitor. Staff and client files will be stored in file cabinet located in the office. Continued on LIC 809-C Bathroom: was observed to be clean and in good repair. Kitchen Space: consisted of a sink, microwave, coffee maker, fire extinguisher, covered trash can, and first aid kit. The reception space consists of a L-shaped desk and ten chairs. Lighting was sufficient and dual smoke/carbon monoxide detector was observed. Space was also observed to have central air and heat. Phone service was observed not to be operable. Emergency exits are located on the east and west end of the building. Princess Wesley has been identified as the Administrator for location. An exit interview was conducted, and a copy of this report will be emailed to Princess Wesley at anewbeginingfoeme6@yahoo.com.


summary: Facility Evaluation

raw_content:
Narrative:
On April 21, 2025, at 9: AM, Licensing Program Analyst (LPA), Erika Butler, conducted a Transitional Housing Placement Program (THPP) Component III office meeting with Applicant,Princess Wesley. LPA Butler met with Applicant to discuss forms required to be maintained, available, and posted at the facility for inspections. We discussed child and personnel records that are required to be documented, retained and available for inspection. We also discussed specific requirements, concerns and issues operating aTHPP, such as, reporting requirements, personnel requirements, supervision, intake issues, compatibility, removal/discharge policies, complaint procedures, transportation, health services, food, hygiene, visitation, personal property, searches, and community sensitivity. Licensing of facility will be April 22, 2025. . A copy of this report was emailed to the Applicant, Princess Wesley.


summary: Facility Evaluation

raw_content:
Narrative:
On July 24, 2025 at 2:15pm Licensing Program Analyst (LPA) Donald Martin arrived at the above office to conduct a Post Licensing Inspection. LPA met with Princess Wesley and was allowed into the office. The program supports up to 8 clients in THPP residences. The office set up is as follows: The Administrators staff office is located at the rear of the office. Next door is the staff bathroom. The bathroom is clean and in order. Outside of the staff office is the kitchen area. There is a sink, coffee maker and a microwave with various snacks below. There is a book shelf with books and toys on top. There are two closets in the area. One containing random storage items and the other contains the air conditioning unit. The entrance has a reception desk with several chairs surrounding it. In this area there are two additional staff offices with desks and chairs. The program has yet to hire staff. The program has yet to take in any clients. There were no deficiencies cited at the time of the visit.

met_with: Princess Wesley-Administrator


facility_name: ALDEA INC

summary: Facility Evaluation

raw_content:
Narrative:
On 02/14/2023, at 1: PM, Licensing Program Analyst (LPA) Connie Goldie conducted an announced inspection and met with Operations Manager, Yuen Chiang. The purpose of the inspection was to conduct a Pre-licensing visit for the relocation of the Transitional Housing Placement Program THPP/ THP+ FC Foster Care. LPA Goldie toured THPP with Office Manager, Yuen Chiang, Compliance/ IT Director, Erin Zamora and Compliance Supervisor , Marie Alvarado and observed the following: The THPP has a waiting area, fire exit plan, fire extinguisher, smoke detectors, and personal rights posters upon entry. There are two private offices for the THPP staff. Within the suite there is a conference/training room which is used as a meeting room for THPP/THP+FC staff . Additionally LPA observed four sound proof "hotel rooms" utilized for participant interviews, a work suite and a mini conference room and 3 visitation rooms for THP+ FC clients. One of the visitation rooms caters to participants with an infant. Staff files and participant files are all electronic for purpose of confidentiality. A kitchen is on site for staff. Care Tool was completed. The following domains were completed: physical plant, operations, disaster preparedness and staffing. Prior to today's visit, the application for the relocation was received and reviewed by the Regional Office. LPA Goldie did not observe any deficiencies in regard to Physical Plant during today's inspection. The agency is ready to be licensed for the Transitional Housing Program pending amended LIC200 to include THP+ FC and forms, LIC500, LIC401, LIC401A and LIC610. An exit interview was conducted at 2: PM with OM Chiang and a copy of this report was left at the facility.

met_with: Office Manager Yuen Chiang


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Orlando Areizaga and Zaria Turner and Licensing Program Manager (LPM) Rosa Rodriguez made an unannounced Annual inspection on Thursday January 13th, 2025 at 9: AM. During the inspection LPAs and LPM met with Supervisor of Resource Family Approval, Narda Oldfield who assisted with the inspection. LPAs Areizaga and Turner and LPM Rodriguez conducted a walk-through of the facility interior. Facility staff at time of inspection were 4. No staff interviewed were conducted. LPAs and LPM observed # 22 office rooms, # 1 kitchen, # 4 conference rooms, # 2 storage rooms, # IT office, # 1 admin office, # 2 therapy rooms, & # 1 lobby. LPAs Areizaga and Turner and LPM Rodriguez were unable to verify the following documentation during today's inspection: · Staff files · Client files · LIC forms LIC 500, LIC 309, LIC 610c During today's inspection the following items are to be revised with current information, rostered personal, and signatures. · LIC 500 · LIC 309 · LIC 610c LPAs Areizaga and Turner and LPM Rodriguez inspected and/or reviewed the following: CONT TO C PAGE Physical Plant: LPA observed the necessary documentation, such as the Facility License, Personal Rights, and Grievance Policies. Cleaning/Disinfectants were secured. Smoke Detectors/Carbon Monoxide were tested and observed in working order. Fire Extinguishers were charged and in 3 locations in the facility. Multiple First Aid Kits were observed throughout the facility to be fully stocked. Fridge was below 45 degrees and Freezer was below 0. Hot water was tested at 110 degrees. Common areas were easily accessible with plenty of seating space for staff. Operations: Reviewed participant names and living units. Disaster Preparedness: Disaster and mass casualty plan updated and available in the entryway. Staffing/Client Records: No staff or client records were available for LPA's and LPM to review. The following items were reviewed for compliance in the regional office prior to the facility inspection: · Annual fees: $0.00 has a credit of $453.00 · Administrator Certificate for: Kimberly Catanzano · Facility Sketch, LIC 308, LIC An exit interview was conducted with Supervisor of Resource Family Approval, Narda Oldfield, and a copy of this report was left at the facility. A continuation Annual inspection will be conducted during the week of 02/17/2025. During the continuation Annual inspection, the following will be reviewed: Staff files, Client files, staff interviews & LIC forms LIC 500, LIC 309, LIC 610c.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Orlando Areizaga and Zaria Turner and Licensing Program Manager (LPM) Rosa Rodriguez made an unannounced Annual Continuation inspection on Wednesday, February 19, 2025 at 9: AM.During the inspection LPAs and LPM met with Program Director, Kim Catanzano who assisted with the inspection. LPAs Areizaga and Turner and LPM Rodriguez conducted a walk-through of the facility interior. Facility staff attime of inspection were 10. 5 staff interviews were conducted. LPAs and LPM observed # 22 office rooms, # 1 kitchen, # 4 conference rooms, # 2 storage rooms, # IT office, # 1 admin office, # 2 therapy rooms, & # 1 lobby. LPAs Areizaga and Turner and LPM Rodriguez inspected and/or reviewed the following domains: Staff Records: Number of Staff files reviewed: 5. All Criminal Record Clearances, Job Title/Qualifications, and Training were verified. Administrator Certificate verified. Client Records: Number of client records reviewed: 5. 5 out of 5 needs and services plans were not signed by participants, a Type B citation was issued during today's inspection. All other required records were in compliance. The following items were reviewed for compliance in the regional office prior to the facility inspection: · Annual fees: Current · Administrator Certificate for: Kimberly Catanzano An exit interview was conducted with Program Director, Kim Catanzano and a copy of this report and appeal rights were left at the facility.

met_with: Program Director, Kim Catanzano


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Dawn Eunice conducted a case management inspection to the above facility for the purpose of ensuring compliance with Interim Licensing Standards, Health and Safety Code and Title 22 regulations regarding the mandate that facilities have a current valid license before operating a Department of Social Services, Community Care Licensing Division facility. On January 31, 2023, an application and licensing fees were received for Aldea Foster Family Agency, Adoption Agency and Transitional Housing Placement Plan facilities. On February 1, 2023 the Department conducted relocation inspections for Aldea Foster Family Agency and the Aldea Adoption Agency. On February 14, 2023, the Department conducted a pre licensing inspection for Aldea Transitional Housing Placement Program. During that inspection, it was discovered that the Aldea facilities were conducting business although the licensing procedures were not finalized for their relocation. Ultimately, the Department did license all three facilities on February 23, 2023. The civil penalty for operating unlicensed is $200.00 per day. In the spirit of collaboration with entities that care for the State's vulnerable client population the Department will assess penalties for 2 days when in fact, all Aldea community care facilities were operating unlicensed over one week. This occurred due to a set of circumstances/oversight by Department staff and the fact that the Aldea community care licensing agencies employed a new Program Administrator. The Program Administrator has complied with the Department's requests for required documentation and now knows the licensing requirements for facility relocations. There is an additional mandate due to the Aldea facility moves. The Department is requiring the Aldea community care licensed facilities to amend their Program Statements. Please ensure they reflect the new addresses for of each of the 3 new locations. Please provide the amended Program Statements by March 31, 2023. On March 8, 2023, Licensing Program Analyst Dawn Eunice delivered this LIC 809, LIC 809D, Appeal Rights, and LIC 421A civil penalty report.

met_with: Karen Lustig, Social Work Supervisor


facility_name: ALTERNATIVE FAMILY SERVICES THP+FC

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Cheyenne McCambridge conducted an unannounced inspection to the facility for the purpose of conducting an Annual/Required inspection and met with Administrator Patty Cala. This inspection was only for the administrative office for the THP+FC. The facility is a three room office suite co-located with the Huckleberry Youth Programs. The facility was toured and is clean, sanitary, and in good repair for the safety and well-being of clients, employees, and visitors. Firearms and other weapons are not stored in the units. Facility has one or more functioning carbon monoxide detectors that meet the statutory requirements. Locking space is available for client documentation. There is currently one youth in placement. Youth and staff files were reviewed and are current and complete with required documentation. No Title 22 deficiencies cited this date. Exit interview conducted and a copy of the report was left with staff.

met_with: Patty Cala


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Cheyenne McCambridge conducted an unannounced inspection to the facility for the purpose of conducting an Annual/Required inspection and met with Administrator Patty Cala. This inspection was only for the administrative office for the THP+FC. The facility is a three room office suite co-located with the Huckleberry Youth Programs. The facility was toured and is clean, sanitary, and in good repair for the safety and well-being of clients, employees, and visitors. Firearms and other weapons are not stored in the units. Facility has one or more functioning carbon monoxide detectors that meet the statutory requirements. Locking space is available for client documentation. There is currently four youth in placement. Youth and staff files were reviewed and are current and complete with required documentation. No client interviews were conducted to clients not wanting to be interviewed. No Title 22 deficiencies cited this date. Exit interview conducted and a copy of the report was left with staff.


summary: Facility Evaluation

raw_content:
Narrative:
On October 9, 2025 at 10:45am, Licensing Program Analysts (LPAs) Celeste Aparicio and Kimberly Hall conducted an unannounced visit to the facility for the purpose of conducting an Annual inspection. LPAs Aparicio and Hall met with Program Director, Sophie Eckert who helped facilitate the inspection. During this inspection LPAs used the CARE Tool to review 6 client files and complete a walk through of the facility. During the facility tour, LPA's observed that the facility is a single story office building that includes 3 sublet office rooms with one of the rooms being a meeting space for the clients in care. Client files are maintained in the in a locked filing cabinet located in one of the staff office rooms. During the review of the client files LPAs identified that medical assessments along with health and education records were unavailable in all client files. LPAs are issuing citations of California Code of Regulations (CCR), Section 86069(a) and Interim Licensing Standards (ILS) for Nonminor Dependents Section 86270(a)(2)(B)(1) Nonminor Dependent Records. (See LIC809-D page) The annual inspection is not complete at this time. A continuation visit will be conducted at a later date to complete this inspection. An exit interview was conducted, appeal rights were discussed and a copy of this report was provided to Program Director, Sophie Eckert whose signature on this form confirms receipt.

met_with: Program Director, Sophie Eckert


summary: Facility Evaluation

raw_content:
Narrative:
On October 17, 2025 at 10:15am, Licensing Program Analysts (LPAs) Celeste Aparicio and Kimberly Hall conducted an unannounced visit to the facility for the purpose of completing Alternative Family Services THP Annual inspection. LPAs Aparicio and Hall met with Program Director, Sophie Eckert who helped facilitate the inspection. During this inspection LPAs used the CARE Tool to review 3 staff files and review the facility's policies on disaster preparedness and operations. LPA's conducted one staff interview. During the review of staff files, LPAs discussed the Administrator qualifications and reviewed staff training. During the review of staff training LPA's identified that staff had no documented training on the THPP's policies and procedures concerning when and how to involve law enforcement in response to an incident involving a participant residing in a THPP living unit. Additionally, LPA's observed there to be no staff training related to the sexual and reproductive rights of youth in foster care. LPAs are issuing citations of California Code of Regulations (CCR), Division 6, Chapter Section 86065(f)(3)(A) and 86065(f)(4). (See LIC809-D pages). The annual inspection is complete at this time. An exit interview was conducted, appeal rights were discussed and a copy of this report was provided to Program Director, Sophie Eckert whose signature on this form confirms receipt.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On October 17, 2025 at 1:50pm, Licensing Program Analysts (LPAs) Celeste Aparicio and Kimberly Hall conducted an unannounced Case Management inspection and met with Program Director/ Administrator, Sophie Eckert. LPA disclosed the purpose of the inspection and was granted entry to the facility by the Program Director. On September 15,2025 at 10:45am and October 3, 2025 at 10am LPAs Aparicio and Hall attempted to conduct the facility's annual inspection. During both inspection attempts neither the Administrator (S1), (please refer to LIC 811, dated 10/17/25 for confidential names), or the Administrators' designee was not available to meet LPAs in the office to conduct the annual inspection. On both occasions (S1) confirmed they were not available and did not have an administrator designee. Also, based on a review of the facility's LIC500 the Administrator is 'On- Call' Monday through Sunday, and no Administrator designee was listed. LPAs are issuing citations of California Code of Regulations, Title 22, Division 6, Chapter Section 86064 (c)(1) and 86064 (c)(2). (See LIC809-D page). An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Program Director, Sophie Eckert whose signature on this form confirms receipt.

Deficiencies:
86064: 1
2
3
4
5
6
7

title:
(c)(2) The administrator shall be responsible for the operation of the THPP... (2) When the administrator is absent during regular business hours, from the THPP, there shall be coverage by the administrator's designee.
This requirement is not met as evidenced by

description:
1
2
3
4
5
6
7


facility_name: AMADOR INSTITUTE, INC.

summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
CCLD has recommended testing, particularly if there has been a known exposure, and has provided guidance on preventative measures, such as wearing masks. PIN 20-19-CRP (combined with ACL No. I-62-20), issued August 13, 2020, states on Page 3, "Foundationally, the residence of a child in care is not a public place, and should be treated as their home, with reasonable effort made to ensure that the experience the child has is as normal as possible. Children therefore are not required to wear face coverings while in their residences, whether that residence is a home-based setting or a congregate care facility." It would be reasonable that this expectation be the same for testing. A facility cannot deny a youth re-entry into their home unit. If the facility is informing the placement agency that they cannot meet the youth's needs due to their behaviors, the facility cannot discharge the youth immediately unless the youth is removed during emergency situations by authorized personnel. The facility must provide the placement agency notice of at least seven days or, following the local placement agency's policy, fourteen days. Based on observations and interviews, the facility required a social worker to pick up R1 from the hospital. The facility provided the reasoning that the facility would not pick up R1 because the hospital was out of county. R1 had been hospitalized on a 5150 psychiatric hold. The facility staff did not respond to the emergency and follow R1 or ensure R1 was safe and then refused to pick up R1 to bring R1 back to their home at the THPP participant unit. Staff also did not facilitate the arrangement of transportation, given the social worker no choice but to pick up R1 themselves. The preponderance of evidence standard has been met, and therefore the above allegations are found to be Substantiated. There are two citations. Due to not following discharge procedure requirements, a citation is being issued per California Code of Regulations, Title 22, Section 86068. Removal and/or Discharge Procedures. Due to not responding to R1's emergency and ensuring R1's safety, a citation is being issued per California Code of Regulations, Title 22, Section Personnel Requirements. An exit interview was conducted, appeal rights provided, and a copy of this report left with Director Dr. Phillips, whose signature on this form confirms receipt.

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

met_with: Director Dr. Phillips; CEO Wayne Phillips


summary: Facility Evaluation

raw_content:
Narrative:
On May 11, 2021, at 12:30 pm, Licensing Program Analyst (LPA) Isabel Mendoza attempted to conduct an unannounced case management inspection. LPA Mendoza arrived at Lone Tree Way, Suite Antioch, CA and Administrative office was closed. LPA Mendoza made several phones calls to Administrator, Patsy Phillips and CEO Wayne Phillips from 12:30 to 1:40 pm. No answer and both voicemail's were full. LPA Mendoza also text messaged both individuals and no response. LPA left copy of the report along with LPA Mendoza's business card. The purpose of the inspection was to follow up on a death incident. The facility contacted Community Care Licensing (CCL) Desk Duty line on May 10, 2021, at 11:09 am. On Friday, May 7, 2021, at 6:02 pm, a participant (P1) (please refer to LIC 811, dated 05/11/21 for confidential names) left the THPP residence, (P1) left behind her two children. (P1) started walking toward Sunset Lane in Antioch. There was a report of gunfire in the neighborhood. Police responded. It was a drive-by shooting. The police found a female victim, and it was (P1). (P1) was pronounced deceased at the site of the shooting. Antioch Police Department notified the facility. The facility reported the incident to CCL via telephone on 05/10/21. Both children are currently with their grandmother. The above incident is currently under investigation by Antioch Police Department, case # 21-3661. CCL is currently in contact with the assigned Detective on this case. Also, is currently requesting the police report and coroners report. During inspection, LPA Mendoza requests the facility to submit an incident report (LIC 624-LE), P1's Needs and Service Plan/TILP, All staff phone numbers, LIC 500 (Staff Schedule) to LPA Mariah Hawkins no later than Friday, 5/14/21. Please Continue to Lic 809-c... At this time, further investigation is still needed. LPA Mariah Hawkins will follow-up with the Administrator on this visit.

met_with: Administrator, Patsy Phillips


summary: Facility Evaluation

raw_content:
Narrative:
On Friday 8/27/21 at 9:57AM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit for the required annual inspection. LPA made pre-visit screening calls to the main office line and to CEO's direct line and left messages with LPA's callback number. LPA was greeted by office staff S2 (See LIC Confidential Names) and met with Administrative Assistant Linda Peete, who Dr. Phillips stated could represent the facility on their behalf today when LPA called Dr. Phillips upon arrival to the office. Dr. Phillips informed LPA that there are currently no residential units under the program. There are also no residents in care. Notification had not been sent to Licensing about the unit(s) no longer being used. At 10:03AM, LPA observed that there was no license posted in the office. An advisory was previously issued regarding this on 5/13/21. LPA printed a copy of the license at visit, and provided to staff to post in the office. At 10:30AM, Administrative Assistant informed LPA that only 1 client file was currently available and that the other files may be in Dr. Phillips' office or at home. Administrative Assistant was able to estimate that there were about 6 youth placed at the program within the last 3 years. Administrative Assistant informed LPA that only 3 of 6 staff files were available for review. LPA reviewed 1 of 6 client files and 3 of 6 staff files and will coordinate with Director for a follow-up inspection. LPA is requesting that Director Dr. Phillips provide LPA the most current LIC 500 and LIC 610, as well as any LIC 9020s Register of Clients, per Title 22, Section 80071(a)(1), for the past 3 years, per Title 22, Section 80070(g). LPA issued six (6) advisories per California Code of Regulations, Title 22, Sections Availability of License, 86031. Notification, Reporting Requirements, Register of Clients, Criminal Record Clearance, Administrator Qualifications and Duties. A follow-up inspection is required to continue the review of facility files that were not available during today's initial inspection. An exit interview was conducted, and a copy of this report was left at the facility.

met_with: Administrative Assistant Linda Peete


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 8/18/22 at 2:42PM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the transitional housing placement program office for a Year Inspection. LPA met with Director Dr. Patsy Phillips and President Wayne Phillips and informed of the purpose of the visit. An initial visit was made on 8/5/22, during which Director and President confirmed multiple times that they would be arriving, but after an hour and 15 minutes, they had not shown and stated they had not left their current location, which they stated was "right around the corner," to make their way toward the office. On 8/18/22, LPA provided an expected window of arrival of noon to 2PM, but at 1:42PM today when LPA arrived, neither the Director nor the President were present. They were called and confirmed they would arrive, but did not arrive until 2:35PM. The worker at the office indicated that she is not authorized to act on behalf of the licensee in any formal way and cannot sign the visit report. Upon arrival, Director informed LPA that she is technically on medical leave and the facility is not operating, which had not been reported to the Licensing agency. LPA is issuing 2 citations per California Code of Regulations, Title 22, Sections Inspection Authority of the Licensing Agency and Administrator Qualifications and Duties and 1 advisory per Reporting Requirements. See attached LIC 809-D and LIC 9102. Licensee was previously cited for Inspection Authority on 5/31/21 and for Administrator Qualifications (Section 86064(a)(2)(A)) on 10/13/21. Due to the repeat violation within 12 months of this section, LPA is issuing an immediate civil penalty of two-hundred and fifty dollars ($250). The CARE Inspection Tool was used to conduct this inspection. There are no residents currently in the program, and the facility does not currently have any participant units. The program also does not currently have any social work / case management staff. The following additional deficiencies were found: 1) The facility does not have an emergency and disaster plan and could not furnish it during the inspection. Staff have not been trained on the emergency and disaster plan. Fire drills have not been conducted quarterly nor in over 3 months. Documentation of fire drills could not be furnished during inspection. LPA is issuing 2 citations and 1 advisory per Health and Safety Code Section 1565. See attached LIC 809-Ds and LIC 9102. 2) The Director and President stated the plan of operation may be in the office, but it could not be furnished during the inspection as LPA nor staff were able to locate it. LPA is issuing 1 advisory per California Code of Regulations, Title 22, Section Plan of Operation. See attached LIC 9102. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Director Dr. Patsy Phillips and President Wayne Phillips, whose signature on this form confirms receipt.

Deficiencies:
80044: 1)

met_with: Director Dr. Patsy Phillips

title:
Inspection Authority of the Licensing Agency and 86064 Administrator Qualifications and Duties and 1 advisory per 86161 Reporting Requirements.  See attached LIC 809-D and LIC 9102.  Licensee was previously cited for Inspection Authority on 5/31/21 and for Administrator Qualifications (Section 86064(a)(2)(A)) on 10/13/21.  Due to the repeat violation within 12 months of this section, LPA is issuing an immediate civil penalty of two-hundred and fifty dollars ($250).
The CARE Inspection Tool was used to conduct this inspection.  There are no residents currently in the program, and the facility does not currently have any participant units.  The program also does not currently have any social work / case management staff.  The following additional deficiencies were found


summary: Facility Evaluation

raw_content:
Narrative:
On 11/03/22 at 11:14AM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility to confirm closure. A forfeiture letter was mailed to the licensee on October 25, 2022, and the facility was officially closed on October 28, 2022. There is no one at the office as no one responded to knocks on the door, and no one answered calls to any of the facility and licensee phones. A copy of this report will be provided to the licensee by certified mail.


summary: Facility Evaluation

raw_content:
Narrative:
On 5/13/21 at 11:40AM, Licensing Program Analyst (LPA) Mariah Hawkins conducted a visit at the licensee office to address deficiencies observed during an investigation of the transitional shelter placement program (THPP). LPA met with Director Dr. Phillips and CEO Wayne Phillips and informed of the purpose of the visit. COVID-19 safety precautions were taken at visit, including masks, disinfectant, hand hygiene, and social distancing. At visit, LPA was greeted by administrative staff upon entry and informed that Director was on the phone. Director greeted LPA at 11:53AM but did not come back out to meet with LPA until 12:03PM, at which point Director informed LPA that she and CEO would be traveling to their personal residence to search for files LPA requested that they were not able to locate in the office. LPA was escorted to the downstairs conference room to wait for their return. Director and CEO returned at 12:48PM. On 2/19/21, LPA initially requested that the following documentation/information be provided to LPA for the complaint investigation: Youth Roster with the names and dates of birth for youth R1 and R2 (See LIC Confidential Names) and R2's twins, R1 and R2's county workers' numbers, and entry dates; Staff Roster with the numbers for the case managers, clinicians, and overnight staff; Incident Reports (IRs) for R1's unauthorized absences; IRs for R1's hospitalization at Children's Hospital in Oakland; Meeting Notes from the recent CFT with R1's social worker. Some of the information requested, including youth's names and dates of birth, staff contact information, and social worker information, was requested to be submitted because Director was unable to provide this information during the visit. At that time, Director stated all would be submitted to LPA by the following day. LPA followed-up on 2/24/21. No response nor documentation had been received by 3/16/21, and LPA followed-up again on that day by phone and email. LPA follow-up again on 3/23/21 and left messages for both Director and CEO. On 3/26/21, Dr. Phillips faxed over the signed visit report from 2/19/21 and two copies of the same incident report for an incident on 2/20/21. On 4/6/21, LPA followed-up again to request the remaining documents be submitted. [CONTINUED ON LIC 809-C Page 2] On 4/13/21, Licensing Program Manager (LPM) Zaid Hakim sent an email to Director restating the need to submit the remaining documentation. On 4/27/21, the documentation had still not been received. LPA spoke to the Director and the licensee's administrative staff to request the remaining documents be submitted to LPA, and Director confirmed that everything would be sent over. On 4/30/21, Director requested that LPA resend LPA's previous emails requesting the documentation for Director to refer to and so Director could have a list of the requested items. LPA reminded Director that the requested items were listed on the report from 2/19/21 and also resent LPA's previous emails. As of today, 5/13/21, the remaining documents have still not been received. Director and CEO returned to the office to continue with visit with LPA at 12:48PM and had retrieved the client files from their personal residence. LPA reviewed the files at 1PM and observed the following to be missing: identification information, any medical records, medical consent forms. Resident R1's (See LIC Confidential Names, dated 5/13/21) file did not contain any paperwork documenting R1's date of birth or R1's needs and services plan or TILP. R2's file contained an application, progress notes, and staff visit check sheets, but there also was no needs and services or TILP. Both R1 and R2 were minors at placement. Additionally, the files were disorganized -- there were seven copies of only one incident report in R1's (See LIC Confidential Names, dated 5/13/21) file, and the reports for the other reportable incidents that Director informed LPA on 2/19/21 had occurred were not in the file; there was an incident report for R1 in R2's file -- and the files were not kept in the office. The other incidents involving R1 that Director had informed LPA on 2/19/21 had occurred included multiple unauthorized absences and a hospitalization at Children's Hospital in Oakland. Director and CEO were unable to provide details of these incidents as no reports were generated for any of the incidents other than the one from 2/20/21, and none had been submitted to the licensing agency within 7 days of the incident, nor was initial next working day notification made. Additionally, during an investigation at the THPP, it was learned that overnight staff S1 (See LIC Confidential Names) did not have a key to the participant unit but did not contact the licensee about the issue. Instead, S1 suggested to R1 that R1 stay the night at S1's personal residence or travel to a friend's house. S1 did not offer to drive R1 to the youth's friend's house, and S1 did not know who the friend was nor confirm it was safe for R1 to stay the night with them. An exit interview was conducted, appeal rights provided, and a copy of this report left with Director Dr. Phillips, whose signature on this report confirms receipt. On 5/13/21, LPA interviewed R2's social worker (SW) Lanz Bañes. R2 was recently killed in a shooting. Refer to LIC Case Management, dated 5/11/21. SW informed LPA that no notice was made to him about the death until he was contacted by R2's family. The THPP did not provide notification to the authorized representative. The THPP is required to submit the written report by tomorrow (5/14/21). LPA will provide Director with the correct licensing form to use to document the incident. Lastly, during today's visit, LPA observed at 11:45AM that the facility license was not visibly posted in the office where visitors can view it. LPA was unable to locate the license. Director informed LPA that they have misplaced their copy of their license and need a new one. Based on the above, the following citations/advisories are being issued at today's visit. Refer to the attached advisory notes and LIC 809-D pages of this report. 1. Due to not furnishing most of the requested documentation and client, staff, or social worker information after multiple requests, a citation is being issued per California Code of Regulations, Title 22, Section Inspection Authority of the Licensing Agency. Please also note that a similar deficiency was previously cited on 6/18/18. 2. Due to not giving notification of incidents nor submitting written incidents reports to the licensing agency of reportable incidents, including R1's multiple unauthorized absences and hospitalization, a citation is being issued per California Code of Regulations, Title 22, Section Reporting Requirements. 3. Due to incomplete client files that were missing medical records, needs and services and/or TILPs, identifying information, a citation is being issued per California Code of Regulations, Title 22, Section Participant Records. Please also note that a similar deficiency was previously cited on 08/14/19. 4. Due to not storing the client files in the office and instead at Director's personal residence, a technical violation advisory is being issued per California Code of Regulations, Title 22, Section Participant Records. 5. Due to staff S1 not ensuring R1 was safe to stay at an unidentified friend's house and not being able to accord the youth with safe home accommodations, a technical violation advisory is being issued per California Code of Regulations, Title 22, Section Personal Rights. 6. Due to not contacting the authorized representative of the death of a youth in care in a timely manner, a technical violation advisory is being issued per California Code of Regulations, Title 22, Section Reporting Requirements. 7. Due to not having the license prominently posted, a technical violation advisory is being issued per California Code of Regulations, Title 22, Section Availability of License.

met_with: Director Dr. Phillips, CEO Wayne Phillips


summary: Facility Evaluation

raw_content:
Narrative:
On Wednesday, September 8, 2021 at 11:15AM, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility (THPP office) for the scheduled annual continuation. LPA scheduled the visit with Director Dr. Phillips and spoke on the phone to confirm the visit the day prior. This annual continuation is to complete the file review, as not all files were available during the initial inspection on 8/27/21. LPA used the Inspection Tool to complete the annual inspection. LPA reviewed all client files and staff files provided in the office. All files reviewed were incomplete. Staff files did not all contain the necessary documentation, such as criminal record clearance, health screening, and training documentation/certifications. The THPP was unable to provide the file for the current social worker. Client files were inconsistent. See LIC Confidential Names for the following: - R1's file was missing admission agreement, identification page, authorized representative contact, photo ID, medical assessment, consent forms, immunization record, needs and services / treatment plans, inventory of cash resources and personal valuables. - R2's file was missing all of the above except the admission agreement and consent forms. - R3's file was missing all of the above except some program notes (meetings, stipends). - R4's file was missing all of the above except admission agreement and some program notes (meetings). - R5's file was missing all of the above except admission agreement, treatment plan, and identification page. 5 other files were reviewed from clients placed before 2018, and all files were missing multiple items. Additionally, residents with children did not have evidence of 1st aid training in their file. LPA issued citations per California Code of Regulations, Title 22, Section Participant Records and Section Personnel Records as well as an advisory per Section Health Related Services. An exit interview was conducted, appeal rights provided, and a copy of this report left with Director Dr. Phillips, whose signature on this form confirms receipt.

met_with: Director Dr. Phillips


summary: Facility Evaluation

raw_content:
Narrative:
On Wednesday 10/13/21 at 10AM, Licensing Program Analyst (LPA) Mariah Hawkins conducted a POC visit at the licensee administrative office. At 10:45AM, LPA met with Administrative Assistant Linda Peete, whom Director Dr. Patsy Phillips verbally authorized, over the phone to LPA, to represent the licensee and sign the reports on Director's behalf. LPA informed both of the purpose of the visit. There are no participants currently in the program. The purpose of the visit was to review the following corrections, per the plans of corrections (POCs) developed on 09/08/2021. The POCs were given an official due date of 10/06/2021, which was also written on top of the copy provided to licensee for clarity. 1. California Code of Regulations, Title 22, Section 86070(b) Participant Records. Type B. The POC was: (1) to submit a copy of the needs and services / TILP their program uses and that will be used for future clients; (2) to submit a training plan that details for current and future staff the program's procedures for ensuring client files contain all necessary documentation, including a list of the necessary documentation. This is the second time this citation has been issued within the past 12 months, so for the repeat violation, LPA issued an immediate civil penalty of $250 with a penalty of $50 per day that will accrue until the correction is completed. 2. California Code of Regulations, Title 22, Section 80066(a) Personnel Records. Type B. The POC was: to submit a training plan that outlines in detail the list of documents needed in each personnel file, how they will be organized in the personnel file, and the procedures by which the THPP will obtain these files. This can serve as an addendum to the program plan. For failure to meet the POC due date, LPA issued a civil penalty of $100 per violation per day since the due date. Additionally, POCs were not received for prior citations issued on 05/13/2021. However, LPA did not make the POC visit within the required time frame. As of today, the corrections have still not been made, so citations were re-issued, per California Code of Regulations, Title 22. 1. 80061(b)(1)(E) Reporting Requirements. Type B. Missing incident reports for resident unauthorized absences were not submitted to Licensing. The POC remains to submit any pending or unsubmitted reports and to develop a training guide for current and future staff that lists the types of incident reports, reportable incidents, and to whom and within what timeframe to submit. This is the second time this citation has been issued within the past 12 months, so for the repeat violation, LPA issued an immediate civil penalty of $250 with a penalty of $50 per day that will accrue until the correction is completed. 2. 86009(a) Availability of License. Type B. The license was not posted in the administrative office. When licensee stated they did not have a license, a one-time copy was printed, and an advisory was issued. Today, LPA observed the license is still not posted in the office. The POC is to visibly post the license in the office. 3. 86064(a)(2)(A) Administrator Qualifications and Duties. Type B. The administrator was not available during the THPP's business hours, and no staff member with administrator's qualifications was designated to cover administrator's duties. Administrative Assistant was off-duty and was called in to the office in place of Dr. Phillips, and neither a LIC 308 nor Linda's file were on site. Linda also does not have full access within the office, so, per staff, some files may be in Dr. Phillips' office or elsewhere. The POC is to demonstrate there is always coverage by qualified and authorized staff. Dr. Phillips arrived at 12:40PM. An exit interview was conducted, appeal rights provided, and a copy of this report left with Dr. Phillips, whose signature on this form confirms receipt.

met_with: Administrative Assistant Linda Peete; Administrator/Director Dr. Phillips


facility_name: ASPIRANET

summary: Facility Evaluation

raw_content:
Narrative:
On 5/17/ Licensing Program Analyst (LPA) N. Sanders conducted an unannounced inspection for the purpose of a case management regarding an incident dated 5/5/2021. LPA spoke with Alexis Peters, Core Program Director (CPD) and discussed the incident. LPA requested the copies of updated contract with the client. No deficiencies were cited.

met_with: Alexis Peters, Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On 6/15/ Licensing Program Analyst (LPA) N. Sanders arrived at the above agency for the purpose of a case management regarding an incident dated 6/7/2021. LPA spoke with Alexis Peters, Core Program Director (CPD) and discussed the incident. LPA collected the following copies : Pictures from the Incident, Pre-Placement Appraisal, Statement of Dangerous Propensities and Client Face Sheet. Interviews were conducted. No deficiencies were cited.


summary: Facility Evaluation

raw_content:
Narrative:
On 6/15/2021 at 11: Licensing Program Analyst (LPA) N. Sanders conducted an unannounced Annual/Required inspection at the above facility. LPA met with Alexis Peters, Core Program Director and a walk through of the agency office was conducted. The office is clean. There is one large conference room, one visitation room, offices for management and cubicles for Life Coaches. First kit has all required items in it. Fire extinguishers are up to date. Cleaning supplies, hygiene supplies and office supplies are locked in storage room. Staff and residents files are locked in cabinets. Program License and Clients Personal Rights are displayed in the lobby. The Program submits incident reports in timely manner. The facility serves 40 residents at this point. The facility has four Life Coaches, one Life Coach Supervisor, one Office Assistant, one House Specialist and one Core Program Director. Core Program Director oversees the entire program. . LPA reviewed six resident's files and 5 staff files. Staff meet education and experience requirements. Staff files contain DOJ, FBI and Child Abuse clearances. First Aid certificates are up to date. Clients files contain: Signed Personal Rights, Admission papers, School and Health records. No title 22 regulations were cited during today's visit. A copy of this report was emailed to Alexis Peters, Coapeters@aspiranet.org Program Director at

met_with: Alexis Peters, Core Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On 7/29/ Licensing Program Analyst (LPA) Jean Stidman along with Public Health Nurse Helen Shi (PHN) and Alexis Peters Core Program Director (PD) conducted a Tele Inspection of the facility via Microsoft Teams due to the facility has one client and one staff with positive COVID-19. It was observed that COVID-19 posters were posted inside and outside the front entrance of the staff office, no clients were present. The client that tested positive has a roommate. The facility is working on contacting the roommate so he can quarantine also. PD stated she is waiting to hear from her corporate office on their procedure for having clients that tested positive. PD stated the staff are on a rotation so that no more than five staff (including three administrative staff) are in the office at the same time. The following recommendations were made: The facility update their local public health today with the client's status of testing positive. The facility check with the clients to see if they have enough food, disinfectant and PPE to last during their 10 day quarantine. If not, the facility is encouraged to provide them with this to avoid the clients going out or using public transportation. The facility will contact the clients to advise them to contact their doctor prior to going to the doctor or instead of going to the emergency room or clinic. The facility will advise clients to view CDC videos on the use of PPE. The facility will advise clients to not have any visitor's during their quarantine. LPA emailed this report to the Program Director with the request to sign and email it back today.

met_with: Alexis Peters Core Program Director