facility_name: BRIGHT PATHS AHEAD

summary: Facility Evaluation

raw_content:
Narrative:
On November 17, 2025, Licensing Program Analyst (LPA) Karen Beal and Licensing Program Manager (LPM) Cheraki Davis met with Applicant Rachelle Cazares to conduct Component II (Face to Face) and to discuss and review the Short Term Residential Therapeutic Program Statement revisions submitted to Community Care Licensing on July 1, 2025. The Applicant was also reminded that all pages in the entire Program Statement and Plan of Operations should be numbered, tabbed, and have clearly titled sections, with all corrections and/or revisions highlighted for ease of reference during the review. Please submit a USB with the Plan of Operation and Program Statement corrections and submit your Administrator's paperwork (transcripts, a copy of your degree, and your Administrator's Certificate). After review of the Plan of Operation/ Program Statement, LPA Beal observed the following: 1. Application for a Community Care Facility (LIC 200)- Does Not Meet Standards · Applicant name should be in the name of the non-profit corporation 2. Orientation Certificate- (Reference CCR § 80018(b)) Meets Standards 3. County Letter of Recommendation (Reference HSC § 1562.01(f) ILS § 87018(c)(6))- Meets Standards 4. Designation of Facility Responsibility (LIC 308) (Reference CCR § 80064)-Does Not Meet Standards · Does not have the Board Resolution designation on the person on LIC 308 · Missing Article of Corporation/ 501(c)(3) · At least one individual must be designated as the authorized person of the STRTP to act in the licensee's absence. 5. Affidavit Regarding Client Cash Resources (LIC 400) (Reference CCR § 80064)- Meets Standards 5. Affidavit Regarding Client Cash Resources (LIC 400) (Reference CCR § 80064)- Meets Standards 6. Surety Bond (LIC 402) (Reference HSC § CCR § 80018) - Meets Standards 7. Monthly Operating Statement (LIC 401) (Reference HSC § 1520(c) CCR § 80018) Does Not Meet Standards · Operating Revenue section is not completed. Cost can be estimated. · Line 38 for Non-Profits must be $0.00 balance. Please correct the figures on the documents. Figures can be estimated, make as realistic as possible. 8. Supplemental Financial Information (LIC 401A) (Reference § 1520(c) CCR § 80018) Does Not Meet Standards · Incomplete 9. Balance Sheet Supplemental Schedule (LIC 403A) Does Not Meet Standards Balance Sheet (LIC 403) Reference HSC § 1520(c), CCR § 80018) Does Not Meet Standards · The document is incomplete. To complete the Balance Sheet LIC 403, first complete the LIC 403a, Balance Sheet Supplemental Schedule. The LIC 403a is a worksheet to be used in compiling the detailed information which is then totaled and displayed on the Balance Sheet, LIC 403. 10. Financial Information Release and Verification (LIC 404) (Reference HSC § 1520(c) CCR § 80018) Meet Standards 11. Personnel Report (LIC 500) (Reference HSC § 1522, CCR § 80018)- Does Not Meet Standards Must specify the days of the week each person is working Section A - Purpose and Goals 1. This section is vague. The purpose and goals do not speak to the nature of the STRTP, which should be to transition youth to a lower level of care. 2. Elaborate on the STRTP's services to attain the goals mentioned. 3. The purpose and goals do not mention individualized care, intensive services, and integrated high-quality short-term care, which are all components of an STRTP. Section D - Staff Plan 1. Explain how the training plan is designed to ensure cultural competency and sensitivity, methods to behaviorally support children are appropriate for children impacted by trauma or child abuse and neglect, and best practices for addressing the permanence, well-being, and educational needs of children, including children with disabilities. 2. Lacks a description of required training of all staff that includes the types of trauma experienced by children and NMDs, the effects and impact of abuse, neglect and trauma, how trauma may manifest itself in daily functioning and behaviors, how to provide care and supervision that is trauma-informed, how to facilitate healing, and how to reduce the risk of re-traumatization. 3. The comprehensive staff training plan does not include the following: · 24 hours of initial training for newly hired direct care staff, comprised of the 8- and 16-hour training: · 8-hour training for newly hired direct care staff · Missing job shadowing · Missing assessment · 16-hour training for newly hired direct care staff within 90 days of hire · Missing assessment · 40 hours of ongoing (annual) training for newly hired and existing direct care staff · 20 hrs. of the 40 hours of training must be of an entity other than the STRTP. · Facility Manager Training · Missing required training topics · Peer Partner and Volunteer Training · Designated employee training related to the application of the reasonable and prudent parent standard. · Emergency Intervention Training 4. The training plan for facility managers and direct care staff does not include the following for each training session: course title and subject matter, learning objectives and activities, number of hours per training session, qualification of the trainer, and training evaluation. 5. The training plan for facility managers and direct care staff shall be designed to ensure the provision of trauma-informed services and be appropriate for the population, and shall consider the training needs and skill level of staff 6. Provide a detailed description of how the program will support caregiver staff in identifying and accessing services and supports to heal from trauma, including, for example, how they will address secondary trauma experienced by staff. 7. Organizational strategies to enhance the well-being of staff are vague. What do the strategies to support staff look like? Please elaborate. 8. Elaborate on how the STRTP will ensure staff are trained to engage with family and community members. 9. Explain how the staff training plan is designed to ensure the provision of trauma-informed services. 10. Explain how the staff training plan is appropriate to meet the needs of staff and the population served. 11. Missing in-service education of staff. G. Admission Determination Procedures 1. Missing procedures that: · Demonstrate the willingness and capacity to assess and determine the appropriateness of placement within the program, consistent with the population to be served on an individualized basis for each child referred by the placing agency. · Consider the child's needs and strengths, the likelihood that the child will benefit from the program, and the extent to which the child's needs are in common with the children currently placed in the facility. 2. Missing the statement that the facility's initial response period shall not exceed 5 days following the receipt of referral for placement. 3. Elevated review is mentioned, but there are no procedures. 4. Missing referral documentation process. 5. Missing procedures for when the STRTP determines that the program is not capable of meeting the youth's needs with and without additional services and/or support. H. Intake Policies and Procedures 1. This section includes intake procedures for NMDs, but in section A, it states that the STRTP does not serve NMDs. Please clarify. 2. Explain HOW the procedures regarding intake will be conducted in a manner that is consistent with trauma-informed practices. 3. The initial crisis management assessment is missing some required provisions. Refer to section 87068.1(d)(1). 4. Missing section 87068.1(c)(1)-(8). 5. Intake for emergency placements are incomplete. Refer to section 87068.1(e). 6. Orientation interview must follow section 87068.1(f)(1)-(2). J. Removal or Transfer Policies and Procedures 1. Missing procedures for removal and/or transfer of children and NMDs as described in Section 87068.1 for each of the following: · After program goals have been reached · When it is determined, program services and support are no longer needed or proven to be ineffective · When it is determined that continued placement in the facility is detrimental to the child or NMD or others in the facility 2. Explain how the licensee will mitigate against potential impacts to a child because of removal or transfer, including but not limited to how the licensee will assist in preventing delays or gaps in delivery of services, types of trauma-informed support and transition services to be provided, and best practices for staff communication with the child during the transition 3. There's mention of notifying the youth/NMD and authorized representative of the removal/transfer process but no procedures to ensure they are informed of removal/transfer policies in an age and developmentally appropriate manner. Missing procedures for both at intake and when notice is given. 4. Missing placement preservation strategies. 5. Need to include a statement that requests for placement changes will not be initiated prior to the first update of the youth's NSP. 6. Need to include a statement that, upon request by either the Department or the STRTP, the STRTP will participate in technical assistance from the Department. 7. Missing section 87068.4(c)(1)-(2). 8. Missing section 87068.4(e)(1)(A)-(F), 87068.4(e)(2)(A)-(E) 9. Missing section 87068.4(b)(1). 10. Emergency removal procedures 11. Missing procedures when STRTP is concerned that it cannot meet a child/NMD's needs or when there is an indication that the placement may be disrupted, including: · Notify authorized representative(s) of the concern. · Communicate the concern to the county placing agency. · Request additional support services from the community if necessary. · Request a Child and Family Team (CFT) Meeting. · Make a reasonably good faith effort to engage in the development and implementation of placement preservation strategies in collaboration with the county placing agency and in consultation with the CFT. 12. Procedures for an NMD to transfer from an STRTP are incomplete. M. Consultants and Community Resources Utilized N. Trauma-Informed Intervention and De-Escalation Techniques 1.This section is vague and does not meet the requirements. Provide a detailed description of trauma-informed and evidence-based intervention and de-escalation techniques that will be used to promote the safety of all individuals in the facility, including but not limited to children or NMDs who have a propensity for behaviors that result in harm to self or others Q. Continuous Quality Improvement (CQI) 1. Explain in detail HOW the CQI will incorporate active inclusion and participation of staff, children/NMDs, families, and community resources, including a description of a process for getting direct input from the children, as age appropriate, to inform program development and improvement. For example, the frequency, who's responsible for distributing the surveys, etc. 2. Explain why it's necessary to review and update the youth's NSP. 3. Elaborate on HOW the CQI will adopt outcomes, indicators, and practice standards, including outcomes associated with trauma-informed and culturally relevant services 4. Elaborate on HOW the facility will utilize data review, analysis, and interpretation to inform and improve policies, practices, and programs. 5. Missing procedures for the evaluation of the STRTP's outcomes and results. 6. What is the role of the Board of Directors? 7. Explain the collection of qualitative and quantitative data and information related to identified outcomes, indicators, and practice standards. 8. Explain how the facility will review, analyze, and interpret the data. Program Statement 1. Population to be Served 1. If the facility plans to serve a specific population, the program statement shall include any details for any specific models or interventions that will be used to tailor their services to their specific population, including the cultural characteristics of that population, the culturally relevant approaches to be used that reflect the diversity within that population, and how the facility will serve lesbian, gay, bisexual, transgender, or queer/questioning children, NMDs, and families. 2. Will the facility accept NMDs age 18 to 21? If so, the program statement shall include a description of programs or services to be provided consistent with assisting an NMD in preparing for the transition to independent living. 3. Does the facility intend to serve children or NMDs with special health care needs? If so, it shall include a statement that it meets all requirements for a specialized STRTP, as defined in ILS Section 87001(s)(5), a description of its program or services to be provided to this population, and a description of how the programs and services meet the requirements as specified in the ILS including, but not limited to, ILS Sections 87010.2, 87064.1, 87065.6, 87066.1, 87068.12, 87069.2, 87070.2, 87072.3, and 87087.1. 4. The program statement does not include a description of how the facility programs can support: I. The individual needs of children, NMDs, and their families, with short-term, specialized, trauma-informed, and intensive treatment, including, but not limited to, treatment that implements child-specific short-and long-term needs and goals identified by the qualified individual's assessment of the child II. Children, NMDs, and their families from different backgrounds or experiences, including race, ethnicity, sexual orientation, gender identity, or a child/NMD who is gender non-conforming. 5. It's not clear if the STRTP intends to serve NMDs age 18-21. Please clarify if so. 4. Core Services and Supports 1. Core services and support need to have more detail on HOW the STRTP will meet these requirements, as specified in Section 87078.1. 3. Describe in detail how the facility will ensure that Indian children receive core services and supports in accordance with the Indian Child Welfare Act, as specified in Section 87078.1(c). 4. Attach agreement(s), if any, with other agencies that provide core services and support, and provide information on how the STRTP will ensure that the core services secured through agreements with other agencies are trauma-informed and culturally relevant. 5. Trauma-Informed Interventions and Treatment Practices 1. Demonstrate in detail HOW the program is trauma-informed by including interventions, practices, services, and supports that recognize and adequately demonstrate how the program addresses each of the following: · A child or NMD's needs to feel safe, respected, informed, connected, and hopeful regarding their own experience with trauma. · The interrelationship between trauma and the impact of trauma includes, but is not limited to, neuro-cognitive problems, neuro-psychological issues such as depression, anxiety, and behaviors. · The need to work collaboratively with a child or NMD, their family and friends, and human services agencies in a manner that will empower the child or NMD. · Interventions, techniques, and practices that are trauma-informed, culturally relevant, age and developmentally appropriate as provided by direct care staff to a child or NMD, consistent with a child's or NMD's needs and services plan and treatment plan. 3. Describe in detail how the STRTP will meet ILS requirements for a comprehensive trauma-informed treatment model designed to address the individualized needs of children as specified in Sections 87022.1 and 87078.2, and include a description of the trauma-informed interventions and/or treatment practices that will be used by the program to serve children, NMDs, and families, as specified in Sections 87022.1(b)(7) and 87078.2, including, but not limited to, the evidence-based or informed screening or assessment tools to identify trauma history and trauma-related symptoms or problems and how that history is included in the child's needs and services case plan or treatment plan within30 days of admission 4. Missing policies and procedures that include prevention services, interventions, practices, services and support must demonstrate the following: · Recognition and understanding of the trauma that children have experienced and how trauma impacts children. · How observable behaviors will be identified and evaluated to assess the need for services. · Maximization of physical and psychological safety for the child or NMD. · How emergency interventions, including early interventions and de-escalation procedures, are trauma informed. · How individualized strategies for trauma-specific interventions address trauma's consequences and facilitate healing, and can be implemented in components including, but not limited to, the needs and services plan and treatment plan and how these strategies are implemented by direct care staff; · Minimization of any potential for re-traumatization. 5. Missing procedures for how the provider will access and make referrals for evidence-based and/or promising services and practices that are trauma-informed 6. Missing policies and procedures for collaboration with Child Welfare, Probation, County Mental Health, CFTs, and outside partners to ensure effective and consistent provision of care and services that are trauma-informed. 7. Provide the procedures for maintaining consistency with TILPS (when applicable). 6. Licensed Nursing Staff 1. If the STRTP is unable to hire a nurse, what's the plan to ensure there is access to nursing services? 8. Missing the following: · The services to be provided or arranged to meet the short-and long-term needs and goals of the child or NMD as assessed by the qualified individual under WIC sections 4096 and 11462.01 · Processes to ensure treatment are consistent with the short-and long-term needs and goals for the child, including as specified in the child's permanency plan · Describe the procedures for the development, implementation, and periodic updating of needs and services plan for children and NMDs, that are trauma-informed, culturally relevant, and age and developmentally appropriate, and procedures for collaborating with the CFT that include a description of the following: · The services to be provided or arranged to meet the short-and long-term needs and goals of the child or NMD as assessed by the qualified individual under WIC sections 4096 and 11462.01 · Processes to ensure treatment are consistent with the short-and long-term needs and goals for the child, including as specified in the child's permanency plan · The anticipated duration of treatment, · Processes to ensure that consistent progress is made toward the timeframe and plan for transitioning the child or NMD to a less restrictive family environment · The procedure to ensure the child or NMD's needs and services plan is consistent with the case plans including the needs as identified by the qualified individual, as developed by the county placing agency and recommendations by the CFT · The procedures to support the reasonable and prudent parent standard, as specified in Section 87067 8. Planned Activities 1. This section includes activities, but there is no clear plan for the following: · Activities that require group interaction. · Planned recreational activities to encourage socialization. · Educational services and remediation. · Activities which meet the training, money management, and personal care, grooming needs, and any other independent living skills identified in the children's/NMD's needs and services plans · Pre-vocational or vocational counseling. · The development of community support systems for children/NMDs to maximize utilization of non-mental health community services and other resources. · Use of the residential environment to assist children/NMDs in the acquisition, testing, and refinement of community living and interpersonal skills. · Access to computer technology and the internet, consistent with the child's age, maturity, developmental level, court order, and CFT decision. 2. The written plan for activities does not demonstrate that it allows children to participate in age or developmentally appropriate extracurricular, enrichment, cultural, and social activities and ensures that the reasonable and prudent parenting standard as specified in Section 87067 will be applied. 3. Please specify if there will be any on-site vocational training courses provided in the facility, including skills taught, goals of the training, hands-on experience received, materials provided, number of hours per day/days per week, and funding. 9. Services During Placement and After Discharge 1. Missing the name, location, and services provided by an agency or agencies that the applicant or licensee has partnered with, either formally or informally, to provide additional supports and services to families and children, including NMDs during care and post-permanency 10. Plan for Participation in Child and Family Team ("CFT") 1. Describe the facility's plan for participation in CFTs, including when the provider will request a CFT meeting if needed. 2. Explain how the facility will participate in CFT meetings in a manner that is trauma-informed, culturally relevant, and age and developmentally appropriate. 11. Identification of Home-Based Settings and Family-Based Aftercare Support Plan and Aftercare Services 1. Provide a detailed description of how the facility, in accordance with the child's case plan and the CFT recommendations, will provide for, arrange for the provision of, or assist in, all of the following: · Identification of home-based settings for a child who does not have a home-based caregiver identified for transition, in accordance with HSC section 1562.01(d)(2)(C)(vii). · Development of an individualized family-based aftercare support plan that identifies necessary support, services, and treatment to be provided for at least six months post-discharge as a child moves from the STRTP to a home-based family care setting or to a permanent living situation through reunification, adoption, or guardianship, or to a transitional housing program. This plan shall be developed, pursuant to WIC section 4096.6, in collaboration with the county placing agency, the CFT, and other necessary agencies or individuals for at least six months' post-discharge. · Aftercare services may be provided by the following, including, but not limited to, a STRTP, county placing agency, child welfare agency, probation department, mental health plan, or other agencies or individuals pursuant to WIC section 4096.6. · Documentation of the process by which the STRTP will implement treatment and services to support the short- and long-term, child-specific mental health goals identified by a qualified individual pursuant to WIC section 4096(g). 12. Family and Sibling Participation 1. Explain in detail how the STRTP will facilitate participation of family members in the child's treatment program, including but not limited to the needs and services plan, the transition plan, and the plan for aftercare services (there's a brief mention, but it's vague). 14. Participation and Assistance in Initiatives to Improve the Child Welfare System 1. Elaborate on the procedures for participation and assistance with any county or state initiatives to improve the child welfare system. 16. Personal Rights 1. Describe policies and procedures that demonstrate compliance with personal rights. 2. The procedures do not include the requirement to explain and advise the child and their authorized representative of personal rights at the request of the child, and each time a new right has been added. 3. Missing the language that personal rights will be explained in a trauma-informed, age and developmentally appropriate manner. 4. Missing the personal rights form. 17. House Rules for Child(ren)/NMDs 1. Describe the House Rules, including how trauma-informed practices are incorporated into the provider's House Rules, and how the house rules are culturally relevant, and age and developmentally appropriate. 2. Explain how the house rules will not violate the personal rights of the youth. 3. Need to be more specific on the house rules. For example, what's the curfew? What are the rules surrounding electronics? What are the chores and how are they assigned? 4. Positive discipline should be captured in section 18. 18. Positive Discipline Policies and Procedures 1. Missing section 87072.1(d)(1)-(5). 2. Missing statement that threats for calling law enforcement will not be used as a form of discipline. 3. Missing statement that youth will not be disciplined for refusing to take their psychotropic medication. 4. Specify the behavior that would prompt positive discipline. 5. Specify the procedures for when the youth is subject to positive discipline. Refer to section 87072.1(e)(1)-(4). 6. Explain how a behavioral contract is trauma-informed . 19. Expectations and Consequences for NMDs 1. Missing statement that threats to calling law enforcement will not be used as a form of discipline. 2. Missing statement that youth will not be disciplined for refusing to take their psychotropic medication. 3. This section mentions New Hope Residence. 4. The types of discipline do not include rationale. Explain how behavioral contracts are trauma-informed and the rationale in using them. 5. Missing section 87072.11(b)(1)-(5). 6. Note consequences need to be temporary. Refer to section 87072.11(e)(1) for the acceptable forms of consequences. 7. Provide procedures for when the NMD is subject to consequences. 22. Child(ren)'s Direct Input 1. Explain how the process for gathering direct input from the youth will be age and developmentally appropriate. 23. Documentation of Accreditation 1. Submit documentation of accreditation, application for accreditation, or declaration of accreditation status with its application for licensure. The STRTP has up to 24 months from the date of licensure to obtain accreditation. 2. Provide documentation to the licensing agency reporting its accreditation status at 12 months and at 18 months after the date of licensure 3. Provide a copy of the final accreditation summary report to the licensing agency within 30 days of its release date 24. Mental Health Program Approval 1. Explain in detail how the facility shall provide or ensure access to mental health services, including specialty mental health services and mental health supports that meet short and long term mental and behavioral health goals and treatment as identified by the qualified individual, as appropriate to the needs of the child or NMD in its care, as outlined in Section 87089.1(d), that shall include all of the following: I. Ensuring the needs and services plan of each child/NMD reflects any mental health needs identified in the case plan, treatment plan, or any available mental health assessment II. Collaborating with the CFT, consistent with the case plan III. Ensuring continuity of care, services, and treatment as a child moves to home-based family care or to a permanent living situation, in accordance with the child's case plan or treatment plan IV. Documenting the child's ability to access mental health services identified in the needs and services plan, or efforts made by the STRTP to ensure access to identified mental health services, including utilization of any existing grievance processes for accessing services. 2. Describe which, if any, of these mental health treatment services the facility will directly provide: · Crisis Intervention · Medication Support Services · Targeted Case Management · Day Treatment Services · Day Rehabilitation Services · Therapeutic Behavioral Services (TBS) · Mental health services · Specialty mental health services · Peer Support 3. Since mental health approval has not yet been obtained, provide a detail description of how the STRTP will provide children in its care access to mental health services to meet the mental health service needs of children, as required by Section 87089.1, including specialty mental health services and mental health supports that meet short and long term mental and behavioral health goals and treatment needs as identified by the qualified individual 4. Explain in detail how the STRTP will provide care and supervision to children diagnosed by a physician, psychologist, or licensed clinical social worker as mentally disordered 26. Emergency Intervention Plan (Runaway Plan) 1. This section is extremely vague. It is recommended to review the regulations and update this section. 2.The EIP was not designed and approved by a behavior management consultant, as required by section 87095.22(a). If a behavior management consultant was not used, the EIP must be designed and approved jointly by the licensee and someone with the qualifications of a behavior management consultant. Refer to ILS for the qualifications and provide the individual's information. 3. Need a clear statement if the STRTP intends to use manual restraints. 4. Explain in detail HOW the Runaway Plan is trauma-informed, culturally relevant, appropriate for the age, size, emotional, behavioral, and developmental level of the child(ren), and account for the particular traumas of specialized populations, including, but not limited to, commercially sexually exploited children. 5. Lacks policies and procedures for discussing runaway plans with each child and their authorized representative at time of admission, as well as how an individualized plan will be developed for with a history of running away or of commercial sexual exploitation 6. Missing protocols for the following: · Employ trauma-informed and evidence-based de-escalation and intervention techniques when staff respond to the behavior of a child residing in the facility · Require staff to undergo annual training on the facility's protocols developed pursuant to HSC section 1531.6. · Specify that contacting law enforcement shall only be used as a last resort once all other de-escalation and intervention techniques have been exhausted, and only upon approval of a staff supervisor · Address contacting law enforcement in an emergency if there is an immediate risk of serious harm to a child or others. · Identify and describe collaborative relationships with community-based service organizations that provide culturally relevant and trauma-informed services to youth served by the facility to prevent, or as an alternative to, arrest, detention, and incarceration for system-impacted youth. 7. Specify staff who will be trained in the Emergency Intervention Plan. 8. Explain in detail how the Emergency Intervention plan incorporates trauma-informed concepts and practices, and how it is: · Be appropriate for the client population served · Be appropriate for the staff qualifications and staff emergency intervention training · Incorporate trauma-informed concepts and practices as outlined in Section 87078.2, where applicable 9. Missing requirements specified in ILS Sections 87095.22(d) through (h). 10. Include a clear statement if the STRTP intends to do manual restraints. If so, include requirements specified in ILS Section 87095.22(f). 11. Admissions Agreement must include a written statement regarding the types of emergency interventions the licensee has been approved to use and must be reviewed with the child/NMD and authorized representative at the time of admission. 12. If the facility will not use manual restraints, the Emergency Intervention Plan must include the following: · Procedures for responding to a crisis to prevent a child who is exhibiting assaultive behavior from injuring or endangering self or others. · Identified and listed external community resources to be used to assist staff. · Policies and procedures on when and how to involve law enforcement in response to an incident involving a child/NMD. Specify that contacting law enforcement shall only be used as a last resort once all other de-escalation and intervention techniques have been exhausted, and only upon approval of a staff supervisor · Address contacting law enforcement in an emergency if there is an immediate risk of serious harm to a child or others. · Identify and describe collaborative relationships with community-based service organizations that provide culturally relevant and trauma-informed services to youth served by the facility to prevent, or as an alternative to, arrest, detention, and incarceration for system-impacted youth. 7. Specify staff who will be trained in the Emergency Intervention Plan. 8. Explain in detail how the Emergency Intervention plan incorporates trauma-informed concepts and practices, and how it is: · Be appropriate for the client population served · Be appropriate for the staff qualifications and staff emergency intervention training · Incorporate trauma-informed concepts and practices as outlined in Section 87078.2, where applicable 9. Missing requirements specified in ILS Sections 87095.22(d) through (h). 10. Include a clear statement if the STRTP intends to do manual restraints. If so, include requirements specified in ILS Section 87095.22(f). 11. Admissions Agreement must include a written statement regarding the types of emergency interventions the licensee has been approved to use and must be reviewed with the child/NMD and authorized representative at the time of admission. 12. If the facility will not use manual restraints, the Emergency Intervention Plan must include the following: · Procedures for responding to a crisis to prevent a child who is exhibiting assaultive behavior from injuring or endangering self or others. · Identified and listed external community resources to be used to assist staff. · Policies and procedures on when and how to involve law enforcement in response to an incident involving a child/NMD. 13. Missing procedure for documenting and maintaining a monthly log of each use of manual restraints 14. Missing procedures for documenting each use of manual restraints in the child/NMDs records 15. Missing procedures for review of manual restraint use 16. Missing procedures for medical examinations, if necessary 17. Missing procedures for the internal biannual review of the use of emergency interventions 18. Missing procedures for the Board of Directors to approve, document, and receive copies of plan 19. Specify if a Protective Separation Room will be utilized. 20. The Runaway Plan is missing requirements specified in ILS Sections 87095.24(c)(1)-(9). 21. The Runaway Plan is missing requirements specified in ILS section 87092.24(e). 22.The time frame for reporting a youth as a runaway is indicated as one hour. Please clarify whether this timeframe applies to all youth in care, regardless of age. Considering that this STRTP intends to serve children between the ages of 6 and 12, the program should carefully evaluate whether waiting up to one hour to report a missing child may pose a safety risk. Continued from LIC 812 11. Personnel Report (LIC 500) (Reference HSC § 1522, CCR § 80018)- Does Not Meet Standards · Must specify the days of the week each person is working · Must include the date employed · Signature required on page two of the LIC 500 · You must have staff coverage to cover 24 hours per day 12. Health Screening Personnel (LIC 503) (Reference CCR § 80018(d)) Does Not Meet Standards · Missing for Marina Cazares 13. Criminal Record Statement (LIC 508) (Reference CCR § 80019) Does Not Meet Standards · Missing for Marina Cazares 14. Emergency Disaster Plan (LIC 610) (Reference CCR § 80023) · Section II needs to include the names of the companies associated with the phone numbers listed 15. Fire Inspection Authority (LIC 9054) (Reference CCR § 80018(d)), CCR § 87018(d)) Does Not Meet Standards · Missing facility information 16. Board of Directors Statement (LIC 9165) (Contained in PUB 326) (Reference CCR § 87018(d)) 17. Control of Property (Reference CCR § 80018(c) Please provide a copy of your deed, tax bill, or mortgage statement to show proof of ownership 18. Bacterial Analysis of Water (Reference CCR § 80021) Please provide a copy of your water bill if you are using public water, or if a well, provide a bacterial analysis 19. Application or Documentation of Accreditation (Reference ILS § 87089) An STRTP shall obtain national accreditation from an entity identified by the department. · The three approved accreditation agencies are: · The Commission on Accreditation of Rehabilitation Facilities (CARF): http://www.carf.org/ · The Council on Accreditation (COA): http://www.coanet.org/ The Joint Commission (JC): http://www.jointcommission.org/

met_with: Applicant, Rachelle Cazares


state: CA

summary: Facility Evaluation

raw_content:
Narrative:
On April 2, 2026, at 10:00am, Licensing Program Analyst (LPA), Karen Beal and Licensing Program Manager (LPM), Cheraki Davis arrived announced at the above facility for the purpose of conducting Pre-licensing inspection at the facility. LPA and LPM were greeted by Rachelle Cazares, Applicant. The Applicant above submitted a Short Term Residential Therapeutic Program (STRTP) application. Presently there are no clients in care at the proposed new location. The STRTP has an approved capacity of six and has obtained the fire clearance. The age range for the clients is 6-17. Upon arrival at the facility LPA and LPM observed that the facility is in a residential community with accessible entry to the front door. The facility is a single-story residential dwelling equipped with four bedrooms and two bathrooms, an attached two car garage, and accessible parking. The pre-licensing facility physical inspection was conducted with the Applicant, Rachelle Cazares. The floor plan of the facility is equipped with a living room, dining room, kitchen, therapy room, a laundry room, a staff office, two bathrooms and four bedrooms. The master bedroom is used as the staff office. It is furnished with a desk and chair, a reclining chair, table and chairs, and a television to monitor the cameras. The master bathroom contains three file cabinets, one cabinet is for staff files, one for client files, and one is for facility binders. The master bathroom stores the medicine cart used to disburse medication. There is also a refrigerator in the staff bathroom for staff use and to be used for the refrigerated medicine locked box. Bedrooms A, B, and C are furnished with two twin beds, two dressers, two laundry baskets, and closet space. ***Continued to LIC 809-C*** ***Continued from LIC 809*** The bedrooms are arranged so that no more than two clients are in a room, and there will be one client per bed. All bedrooms will be utilized for client use and have two beds per room. All bedding was found to be clean, and ready to use condition. There are cameras located in the kitchen, the hallway by the laundry room, the garage, a camera that faces the whole hallway and entry door, the staff office, and in the living room. Two cameras in the back yard. One camera is facing the left side of the facility where there is an unlocked exit gate, and second camera is pointing at the open space of the backyard. LPA observed age-appropriate books, games, and puzzles for clients. Knives are kept in a locked cabinet located in the staff office bathroom area and are made inaccessible to clients. The Applicant have sufficient dishes, cups and silverware for client use and the electric stove is in working order. The Applicant has four working fire extinguishers, one located in the garage, second is located outside of the staff office, third is in the pantry, and the fourth is located near the patio exit door. Carbon monoxide and smoke detectors were observed and in working order. There is a landline telephone that is in working order that will be available to clients. There were no observable hazards or obstructions by the walkways and entries/exits of the facility. There are no pools or other bodies of water present. The backyard has a patio/bench table and with an umbrella. The backyard (grass/dirt/weeds) will be renovated at later time. The central air conditioner unit is in the backyard located on the left side of the home. There is a locked closet in the hallway observed with an ample storage for client toiletries and linen. Medication is centrally stored in a locked box located in the staff office. LPA tested the water, and it read at 111.5 degrees Fahrenheit. The Applicant was advised that the hot water should measure within 105 degrees Fahrenheit and 120 degrees Fahrenheit. Components three will be conducted at a later time. All special incidents reports will be sent via email to: cclpaccr@dss.ca.gov. LPA explained that once the license is approved, all employees shall have an approved criminal record clearance for CCL and be associated to the facility. The application and this report will be reviewed for approval. Once the application is approved a license will be issued.

report_type: Facility Evaluation

visit_type: Prelicensing

met_with: Rachelle Cazares, Administrator


facility_name: BRIGHTER DAY STRTP

summary: Facility Evaluation

raw_content:
Narrative:
On 06/25/2025 at approximately 9: AM Licensing Program Analyst (LPA) Sara Luman-Gonzalez and Licensing Program Manager (LPM) Rosa Rodriguez conducted an in-person Component II with the above facility for the purposes of discussing compliance and regulations. Present during the meeting were LPA Sara Luman-Gonzalez, LPM Rosa Rodriguez, Chief Executive Officer Ayan Hill, and attending virtually via Microsoft Teams is Facility Administrator Radiance Clinton. Below is a summary of the topics that were discussed and the answers that were provided by the licensees: Program Statement/Plan of Operations - LPA and LPM reviewed the LIC 9106 to discuss updates needed. Licensee stated they will update necessary sections of the LIC 9106 and Program Statement to reflect current program and population. Licensee stated they will begin the review and submit the updated Program Statement and LIC 9106, with highlighted changes, to the department by July 9, 2025. LPA and LPM will review the new Program Statement to determine if the new revisions are in compliance with the department regulations. Section D- Staff Plan Section G- Admissions Section H- Intake Procedures Section J- Removal or Transfer Policies and Procedures- Section M- Consultants Section N- Trauma Informed Intervention and De-Escalation- Section Q-Continuous Quality Improvement (CQI) Client Population Served 4. Core Services 5. Trauma Informed Interventions and Treatment Practices 6. Licensed Nursing Staff- 7. Development, Implementation, and Modification of Needs and Services Plan 8. Planned Activities- 9. Services During Placement and After Discharge 10. Plan for Participation in Child, Family, Team (CFT) Meetings 11. Identification of Home-Based Settings, Development of Individualized Aftercare Support Plan, & Documentation of Process to Implement Treatment and Services 12. Family and Sibling Participation 17. House Rules for NMD/Children-117 18. Positive Discipline Policies and Procedures 19. EXPECTATIONS AND CONSEQUENCES FOR NMDs 22. Child(ren)'s Direct Input 23. Documentation of Accreditation-131 24. Mental Health Program Approval 26. Emergency Intervention Plan (Runaway Plan) Exit Interview was conducted and a copy of this report was provided to the Applicant.

met_with: Ayan Hill, Chief Executive Officer and Radiance Clinton, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 9/19/25 at approximately 9: A.M., Licensing Program Analyst (LPA) Sara Luman-Gonzalez arrived at the facility for the purpose of conducting a pre-licensing inspection for a SHORT TERM RESIDENTIAL THERAPEUTIC PROGRAM (STRTP) license. LPA met with Ayan Hill, Licensee (L) and Radiance Clinton, Facility Administrator (FA) who granted LPA entry into the facility. During the visit, LPA utilized the CARE Tool to conduct a Health and Safety Inspection of the facility. LPA observed the interior and exterior of the facility to be clean and safe. LPA observed that the facility is a two-story residence with five bedrooms and three bathrooms. One bedroom will be shared by two youths and the remaining four are all single rooms. All bedrooms and bathrooms have adequate furniture, linens, supplies, and equipment for the capacity of the facility. Sufficient storage space for client's personal belongings was observed in each room. All three bathrooms will be accessible to clients. Water temperature was tested and found not the exceed 120 degrees F.The facility is requesting to be licensed for six female youths ranging in age from 12 to 17 years old + 18 years old if youth is 17 years old upon placement. LPA observed the locked medication box and petty cash box in a locked cabinet in a locked garage, which is also utilized as a staff office. Staff will be the only ones to access this area and LPA observed where the spare keys are kept in an emergency. Two locked boxes with cleaning chemicals and spare feminine hygiene products are also kept in the garage. A small fridge will be purchased in the near for refrigerated medications. The kitchen area was equipped with an adequate amount of utensils, dining supplies, and cups for clients. No food was observed as there are no clients, and no pending placement at this time. Facility will verify required food on hand at time of client placement. (Cont. on LIC 809C) A fully equipped first aid kit was reviewed and is placed in the staff office and the pantry. LPA observed the spare pantry where there was extra food storage and emergency supplies. Licensee will purchase, in the near future, a generator for power backup incase of blackout. Brighter Day STRTP's physical plant is adequately prepared to accept clients. After completing and finalizing the Program Statement/Plan of Operations, LPA will print LIC 203A for the facility. An exit interview was conducted and a copy of this report was given to Licensee.

met_with: Ayan Hill, Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On December 18, 2025 at approximately 10: AM, Licensing Program Analyst (LPA) Orlando Areizaga made an unannounced visit to the Short Term Residential Therapeutic Program (STRTP) for the purpose of conducting a case management. LPA Areizaga met with Facility Manager, Jenni Mendoza who granted LPA access to the facility. On November 25, LPA Areizaga received an Incident Report (IR). The date the IR occurred was November 17, 2025. Based on file review, LPA Areizaga confirmed that the STRTP did not meet the reporting requirements, as no 24 hour notification nor a 7-day follow up report was submitted to the department at the time the STRTP was aware of the incident. The licensee is being given an LIC Technical Violation for failure to report an incident. This report was discussed with Facility Manager, Jenni Mendoza and a copy of this a copy of the report and appeal rights were printed and left at the facility.

visit_type: Case Management

met_with: Facility Manager, Jenni Mendoza


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On December 18, 2025 at approximately 10: AM, Licensing Program Analyst (LPA) Orlando Areizaga made an unannounced visit to the Short Term Residential Therapeutic Program (STRTP) for the purpose of conducting a case management. LPA Areizaga met with Facility Manager, Jenni Mendoza who granted LPA access to the facility. On December 18,2025 during a facility inspection LPA noted a 3 to 4 foot sized hole in a closet door. LPA asked Facility Manager (FM) Mendoza about the door. FM stated the door was broken due to an incident with a client. LPA confirmed the closet door was broke and in bad repair. LPA is issuing a LIC809-D for 80087(a) Buildings and Grounds. This case management is to remain open until proof of the deficiencies are cleared. This report was discussed with Facility Manager, Jenni Mendoza and a copy of this a copy of the report and appeal rights were printed and left at the facility.

Deficiencies:
80087(a): (a)

title:
1
2
3
4
5
6
7Buildings and Grounds

description: (a)


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Manager (LPM) Hillary Hall arrived unannounced at the facility on this date for the purpose of a case management following a records review. LPM reviewed records from the facility including allowance logs, personal property inventory, admissions/placement agreements, Needs and Services plans, and Social Worker Progress notes. Five facility staff were interviewed. Upon review, two client allowance logs (LIC 405) did not reflect client or staff signatures. One LIC 405 was pre-filled for dates following the client's exit from the facility. The balance listed for the clients was not mathematically correct. One client report not receiving their remaining balance of allowance upon discharge. Five Updated Needs and Services Plans were reviewed, for four different clients. Needs and Service plans were not signed by the clients. One of the five Needs and Services Plans was signed by the authorized representative, but verification was provided of two Needs and Services Plans having been sent to the authorized representative, requesting a signature. All five Needs and Services Plans failed to reflect collaboration with the client or Child and Family (CFT) team in developing the plan. All five plans did not document age-appropriate discussions with the client. Two Initial Needs and Service plans were provided for two different clients than the Updated plans which were provided. The two initial reports appeared to be written by the facility CEO and were dated the day of, or day after the clients were placed and did not indicate collaboration with the client or CFT. The two initial reports were not signed by the client. Continued from Placement agreements for two youth were reviewed. Neither had signatures of the clients, or documented attempts to obtain signatures. Signed copies of Removal/Transfer policies were also requested from the facility, but were not provided. Facility director reported via email that these policies are only reviewed verbally with the clients and that client signatures were not obtained as they "unable to provide legal consent." Three citations are being issued for violating Interim Licensing Standards: Section 87072 (c) (36): Personal Rights The licensee shall ensure that each child, regardless of whether the child is in foster care, is accorded the personal rights specified in Welfare and Institutions Code Section 16001.9, and below, as applicable: (36) To receive an age-appropriate allowance. Section 87068.3(b) Modifications to The Needs and Services Plan (b) The licensee shall ensure that the child and their authorized representative(s) are offered the opportunity to participate in such modifications. (1) The licensee shall not implement any plan modifications unless prior written approval of such modifications has been obtained from the child's authorized representative(s). (2) The licensee shall consider the recommendations of the child and family team while implementing modifications to the needs and services plan. 87068.1(c)(4) Intake Procedures (c) When a child has been accepted for nonemergency placement in a short-term residential therapeutic program, the following requirements shall be met... (4) The administrator or their designee, and the child and/or their authorized representative(s), shall sign copies of: the removal and/or transfer policies and procedures specified in Section 87068.4(a); of the discipline policies and procedures specified in Section 87072.1(a); and of the complaint procedures specified in Section 87072.2(a), to verify the receipt of such information. A signed copy of this LIC-809 report, the LIC-809C, and LIC-809D were provided to the facility. An exit interview was conducted. Appeal rights were provided.

met_with: Junior Paminsan, Director


summary: Facility Evaluation

raw_content:
Narrative:
On March 3, 2026, at approximately 10: AM Licensing Program Analyst (LPA), Orlando Areizaga conducted an unannounced visit to the above facility for the purpose of conducting a Post Licensing inspection. LPA met with Junior Paminsan, Director and walk through of the interior and exterior of the facility was conducted. There are currently (1 of clients) residing in the facility. LPA conducted a walk-through of the interior and exterior of the facility. There was 1 staff and 1 client present during the time of the inspection. LPA observed 5 bedrooms, 2.5 bathrooms, 2 living room, 1 kitchen, 1 laundry room, 1 garage, 1 outdoor shed with extra facility paint, and 1 facility van with updated registration and insurance. The following domains were observed: 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 observed in working order. Fire Extinguishers were charged and in 2 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 130 degrees. Common areas were easily accessible with plenty of seating space for staff and clients Operations: Reviewed documents needed for inspection Disaster Preparedness: Disaster and mass casualty plan updated and available in the entryway. Emergency Interventions: Reviewed documents needed for inspection. Cont to C-page Staffing: LPA reviewed 2 staff files. Clients Records: LPA reviewed 1 client file. Special Health Care Needs: Reviewed documents needed for inspection Core-Therapeutic Services: Reviewed documents needed for inspection Based on a review of the facility's Guardian Roster the staff working during today's inspection are fingerprint cleared and associated to the facility. During todays inspection the hot water was observed and tested at 130 degrees F. The facility is being cited for California Code of Regulations (CCR) 80088(e)(1) Furniture, Fixtures, Equipment, and Supplies on the attached LIC809D. Exit interview was conducted with Junior Paminsan, Director, a copy of this report and Appeal Rights were discussed and provided to the licensee.


summary: Facility Evaluation

raw_content:
Narrative:
On March 11, 2026, at approximately 10: AM, Licensing Program Analyst (LPA) Orlando Areizaga arrived at the above Short-Term Residential Therapeutic Program (STRTP) for the purpose of conducting a Case Management deficiency. LPA was greeted by Director, Junior Paminsan who granted LPA access. Community Care Licensing (CCL) determined that Director (D) Rogelio "Junior" Paminsan is not qualified to be an administrator. CCL informed Executive Director (ED) Ayan Hill that D was not qualified on 02/04/26, and ED would need to send an update on the hiring process within 10 days. ED notified the CCL that ED and D will split the Administrator duties. LPA Areizaga requested ED's STRTP Administer package on 02/27/26, 03/03/26 and 03/05/26. As of today March 11, 2026, Brighter Day STRTP has not submitted a qualified candidate for the Administrator role. Based on records review and interviews, the above STRTP is being cited per Interim Licensing Standard (ILS) 87064(b) Administrator Qualifications and Dutieson the LIC809-D. An exit interview was conducted with Director, Junior Paminsan. A copy of this report and Appeal Rights were left at the facility.

met_with: Director, Junior Paminsan


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Continued from It was alleged staff withheld minor's personal property. Two minors were not provided all of their personal property and medications upon discharge. LPM observed the personal property of the two minors, in garbage bags at the facility, after the minor's had been discharged. Interviews were consistent that the facility did not allow the minors to assist in packing their belongings. One minor returned to the facility after discharge to retrieve their property, but was denied access by staff and not given their remaining belongings. One minor's authorized representative emphasized the minor had a right to retrieve their own belongings, and that the authorized representative had given permission for the minor or their delegate to pick them up. LPM reviewed the Personal Property inventories for two minors. The inventories provided did not have the required signatures or any dates, and did not specify if all items listed were returned to the minors upon discharge. The records provided indicated the facility did not follow the policies in their Program Statement regarding safeguarding the personal property of minors in care. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. Citation is being issued for violating Interim Licensing standards Section #87022(f) Plan of Operation. A signed copy of this LIC-9099 report, the LIC-9099C, and LIC-9099D were provided to the facility. An exit interview was conducted. Appeal rights were provided.

Investigation Findings:
13Licensing Program Manager (LPM) Hillary Hall arrived unannounced at the facility on this date for the purpose of delivering findings for the complaint investigation. LPM met with Junior Paminsan, Director. LPA Lyta Vue and Licensing Program Manager (LPM) Hillary Hall conducted the complaint investigation. Licensing Program Manager (LPM) Hillary Hall initiated the investigation with the facility on 1/29/26, interviewed two staff, and conducted a Health and Safety Inspection. During the course of the investigation, LPA and LPM interviewed three additional current and former staff, three county social workers, a probation supervisor, one client, and three other confidential individuals. LPM reviewed records including: Placement Roster, Needs and Services Plans, Social worker case notes, prior complaint history, Serious Incident Reports, Child and Family Team Meetings notes, Personal Property inventory, allowance logs, LIC-500 personnel report, background clearances, and Plan of Operation/Program Statement. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Danielle Walker-Flores LICENSING EVALUATOR NAME: Hillary Hall 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHICO - RESIDENTIAL, COHASSET RD., STE. FACILITY NAME: BRIGHTER DAY STRTPFACILITY NUMBER: VISIT DATE: 02/27/2026

report_type: Complaint Investigation

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Continued from It was alleged licensee did not provide minor's authorized representative the opportunity to participate in the development of a transfer plan for the youth. One youth was given a "14-day notice" with the email from the facility to the authorized representative indicating the youth needed to be removed within 10 days. The youth's treatment team was not consulted prior to the notice regarding placement concerns. Some of the reasons given for the notice were not appropriate such as "not attending CFT's," as this is the client's personal right. A second youth was also given a 14-day notice, with reasons given including the youth refusing school attendance and declining medical services, which is also the youth's personal right. Three other youth were given immediate 24-hour notices without requests to their authorized representatives for CFT's or placement preservation meetings. In an interview, the Director indicated the facility had not given notice on any youth, however, records indicate otherwise. Based on LPA and LPM's interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. Citation is being issued for violating Interim Licensing standards Section 87068.4(b): Removal and/or Transfer Procedures. A signed copy of this LIC-9099 report, the LIC-9099C, and LIC-9099D were provided to the facility. An exit interview was conducted. Appeal rights were provided.

Investigation Findings:
13Licensing Program Manager (LPM) Hillary Hall arrived unannounced at the facility on this date for the purpose of delivering findings for the complaint investigation. LPM met with Junior Paminsan, Director. LPA Lyta Vue and Licensing Program Manager (LPM) Hillary Hall conducted the complaint investigation. Licensing Program Manager (LPM) Hillary Hall initiated the investigation with the facility on 1/29/26, interviewed two staff, and conducted a Health and Safety Inspection. During the course of the investigation, LPA and LPM interviewed three additional current and former staff, three county social workers, a probation supervisor, one client, and 2 other confidential individuals. LPM reviewed records including: Placement Roster, Needs and Services Plans, Social worker case notes, prior complaint history, Serious Incident Reports, Child and Family Team Meetings notes, Personal Property inventory, allowance logs, LIC-500 personnel report, background clearances, and Plan of Operation/Program Statement. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Danielle Walker-Flores LICENSING EVALUATOR NAME: Hillary Hall 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHICO - RESIDENTIAL, COHASSET RD., STE. FACILITY NAME: BRIGHTER DAY STRTPFACILITY NUMBER: VISIT DATE: 02/27/2026


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Continued from Two interviews provided statements that youth were not afforded culturally appropriate hygiene products. One outside service provider purchased culturally appropriate hygiene items for a youth because the facility would not do so. Staff interviews provided inconsistent information regarding how much money was provided for youth hygiene items, and how this was documented. Additionally, policies regarding hygiene changed after youth were placed, contributing to misunderstandings between staff and youth. Records were requested documenting money spent or allotted for culturally appropriate hygiene items. Two undated photos of the youth were provided. Three LIC- Personal Property forms were provided without clear dates or signatures. Based on LPA and LPM's interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. Citation is being issued for violating Interim Licensing standards Section 87072(c )(8)(B)(1). A signed copy of this LIC-9099 report, the LIC-9099C, and LIC-9099D were provided to the facility. An exit interview was conducted. Appeal rights were provided. Continued from It was alleged staff denied youth in care transportation to school. Interviews were consistent that on one occasion, staff transported a youth to school, but there was mis-communication regarding if the youth was staying for the full day or just briefly dropping off school property. When the staff left the youth at school, the youth had to then call the staff to come back and pick them up. The youth waited 30-60 minutes at the school to be picked up. Records and interviews did not identify other incidents of transportation not being provided to or from school. Based on LPA's interviews which were conducted, and records reviewed, although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove the violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED. A signed copy of this LIC-9099 report and the LIC-9099C were provided to the facility. An exit interview was conducted. Appeal rights were provided.

Investigation Findings:
13Licensing Program Manager (LPM) Hillary Hall arrived unannounced at the facility on this date for the purpose of delivering findings for the complaint investigation. LPM met with Junior Paminsan, Director. LPAs Tina Thorn and Lyta Vue and Licensing Program Manager (LPM) Hillary Hall conducted the complaint investigation. LPA Thorn initiated the investigation with the facility on 1/22/26, interviewed one staff and one youth, and conducted a Health and Safety Inspection. During the course of the investigation, LPAs and LPM interviewed three additional current and former staff, three county social workers, a probation supervisor, one additional youth, and two other confidential individuals. LPM reviewed records including: Placement Roster, Needs and Services Plans, Social worker case notes, prior complaint history, Serious Incident Reports, Child and Family Team Meetings notes, Personal Property inventory, allowance logs, LIC-500 personnel report, photos, and Plan of Operation/Program Statement. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Danielle Walker-Flores LICENSING EVALUATOR NAME: Hillary Hall 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHICO - RESIDENTIAL, COHASSET RD., STE. FACILITY NAME: BRIGHTER DAY STRTPFACILITY NUMBER: VISIT DATE: 02/27/2026

complaint_status: unsubstantiated


raw_content:
Narrative:
Continued from Three interviews provided information regarding condescending comments made by staff to youth. Two youth expressed being uncomfortable with male staff. Instead of mitigating the youth's concerns, the feelings of one youth were cited as a reason for giving notice on the youth. A comment was made to a youth threatening to send the youth back to jail. The youth expressed a desire for additional counseling, and was then given notice, with the youth's request for counseling cited as a reason for the notice. Records submitted by the facility indicate a lack of awareness by staff of trauma informed care, with the facility not ensuring the youth are treated with respect in relation to their trauma. Based on LPA and LPM's interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. One citation is being issued for violating Interim Licensing standards Section 87072(c)(1): Personal Rights. A signed copy of this LIC-9099 report, the LIC-9099C, and LIC-9099D were provided to the facility. An exit interview was conducted. Appeal rights were provided. Continued from Staff interviews reported youth are provided with three meals a day, plus snacks. LPM conducted a Health and Safety Inspection on 1/29/26 and observed a variety of snacks on the counter available to youth, as well as the required amount of fresh and non-perishable food on hand in the facility. One youth reported not liking the options of food, but the youth agreed that food was provided. Records provided included a menu documenting meals and snacks provided to youth for December 2025-January 2026. Menu documented an assortment of foods provided to youth. Based on LPA's observations, interviews which were conducted, and records reviewed, although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove the violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED. A signed copy of this LIC-9099 report and the LIC-9099C were provided to the facility. An exit interview was conducted. Appeal rights were provided.

Investigation Findings:
13Licensing Program Manager (LPM) Hillary Hall arrived unannounced at the facility on this date for the purpose of delivering findings for the complaint investigation. LPM met with NAME, TITLE. LPAs Tina Thorn and Lyta Vue and Licensing Program Manager (LPM) Hillary Hall conducted the complaint investigation. LPA Thorn initiated the investigation with the facility on 1/22/26, interviewed one staff and one youth, and conducted a Health and Safety Inspection. During the course of the investigation, LPAs and LPM interviewed three additional current and former staff, two county social workers, a probation supervisor, and one additional youth. LPM reviewed records including: Placement Roster, Needs and Services Plans, Social worker case notes, complaint history, Serious Incident Reports, Child and Family Team Meetings notes, Personal Property inventory, allowance logs, LIC-500 personnel report, and Plan of Operation/Program Statement. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Danielle Walker-Flores LICENSING EVALUATOR NAME: Hillary Hall 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHICO - RESIDENTIAL, COHASSET RD., STE. FACILITY NAME: BRIGHTER DAY STRTPFACILITY NUMBER: VISIT DATE: 02/27/2026


raw_content:
Narrative:
Continued from It was alleged staff did not safeguard minors personal belongings. The Facility Manager and Director reported not having inventoried a minors personal belongings upon intake and could not therefore verify if the minor's high valued belongings were not safeguarded, or if they were ever brought to the facility in the first place. Personal property inventory records reviewed did list high valued items, but did not have names or dates. One minor returned from a home visit and no staff were present to receive the minor, leaving the minor and parent to wait approximately 90 minutes. The staff schedule indicates the Facility Manager was scheduled to work at the facility that day, however, Facility Manager did not confirm this. The Director indicated the staff scheduled to work was out shopping, leaving the minor and parent to wait. Interviews and records were unable to confirm if the minor returned to the facility unexpectedly. Based on LPA's interviews which were conducted, and records reviewed, although the allegations may have happened, or are valid, there is not a preponderance of evidence to prove the violations did, or did not, occur. Therefore, the allegations are UNSUBSTANTIATED. A signed copy of this LIC-9099 report and the LIC-9099C were provided to the facility. An exit interview was conducted. Appeal rights were provided.

Investigation Findings:
13Licensing Program Manager (LPM) Hillary Hall arrived unannounced at the facility on this date for the purpose of delivering findings for the complaint investigation. LPM met with Junior Paminsan, Director. LPAs Orlando Ariezaga, Tina Thorn, and Lyta Vue, and Licensing Program Manager (LPM) Hillary Hall conducted the complaint investigation. LPA Ariezaga initiated the investigation with the facility on 1/08/26, interviewed two staff and one minor, and conducted a Health and Safety Inspection. During the course of the investigation, LPAs and LPM interviewed three additional current and former staff, two county social workers, a probation supervisor, one additional minor, and three other confidential individuals. LPM reviewed records including: Placement Roster, Needs and Services Plans, Social worker case notes, Serious Incident Reports, Child and Family Team Meetings notes, Personal Property inventory, allowance logs, LIC-500 personnel report, and Plan of Operation/Program Statement. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Danielle Walker-Flores LICENSING EVALUATOR NAME: Hillary Hall 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHICO - RESIDENTIAL, COHASSET RD., STE. FACILITY NAME: BRIGHTER DAY STRTPFACILITY NUMBER: VISIT DATE: 02/27/2026


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
On August 11, 2023, Licensing Program Analyst (LPA) Lisa Slusher was met by Administrator Nikkia Moton for the purpose of closing the investigation with regards to the above allegations. During the course of the investigation, LPA conducted confidential interviews and obtained copies of documents. Based on confidential interviews and other documents obtained during the investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. The agency is being cited in Interim Licensing Standards V4, Short term residential therapeutic programs section 87072(c)(10) and 87072(c)(11). An exit interview was conducted, and a copy of the report and appeal rights were provided to the facility SubstantiatedEstimated 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 Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, E SHAW AVE FACILITY NAME: BRIGHTER HORIZON TREATMENT CENTERS, COTTONWOODFACILITY NUMBER: 107207215

met_with: Nikkia Moton


facility_name: BRIGHTER HORIZON TREATMENT CENTERS, COTTONWOOD

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 Administrator Nikkia Moton. 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


investigation_findings: 13On 11/22/23, Licensing Program Analyst (LPA) Lisa Slusher conducted an unannounced complaint investigation for the above facility. Met by Administrator Nikkia Moton. 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


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Lisa Slusher met with the administrator for the purpose of resolving a complaint investigation at the Short Term Residential Therapeutic Program (STRTP) and met with Administrator Nikkia Moton. During the course of the investigation LPA conducted confidential interviews and reviewed documentation. 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 sent to the Facility Manager. 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 Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE FACILITY NAME: BRIGHTER HORIZON TREATMENT CENTERS, COTTONWOODFACILITY NUMBER: 107207215

met_with: Carolyn Ruffin


raw_content:
Investigation Findings:
13On 11/28/23, Licensing Program Analyst (LPA) Lisa Slusher conducted an unannounced complaint investigation for the above facility. Met by Facility Manager William Zachary. 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 sent to the Facility Manager. 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: William Zachary


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On this date, Licensing Program Analyst (LPA) Leslie Inouye conducted a complaint inspection for the Short Term Residential Therapeutic Program (STRTP) for the purpose of delivering the findings for the above complaint allegation. LPA met with Administrator Nikkia Moton. During the course of the investigation LPA conducted confidential interviews and reviewed documentation. Investigation shows that facility has not consistently maintained adequate care and supervision. The allegation is substantiated. A citation is issued on this date pursuent to CCR Title General licensing regulations section 80078(a) Responsibility for providing care and supervision SubstantiatedEstimated 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 Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE FACILITY NAME: BRIGHTER HORIZON TREATMENT CENTERS, COTTONWOODFACILITY NUMBER: 107207215


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On this date, Licensing Program Analyst (LPA) Lisa Slusher conducted a complaint inspection for the Short Term Residential Therapeutic Program (STRTP) for the purpose of delivering the findings for the above complaint allegation. LPA met with During the course of the investigation LPA conducted confidential interviews and reviewed documentation. Investigation shows that facility has not consistently maintained adequate care and supervision. The allegation is substantiated. A citation is issued on this date pursuent to CCR Title General licensing regulations section 80078(a) Responsibility for providing care and supervision. A civil penalty is noted on a separate document for the same section on this date. SubstantiatedEstimated 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 Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE FACILITY NAME: BRIGHTER HORIZON TREATMENT CENTERS, COTTONWOODFACILITY NUMBER: 107207215


raw_content:
Investigation Findings:
13Complaint Specialist C.K. Kinney(CS) traveled to Brighter Horizons Treatment Center-Cottonwood and met with William Zachary to deliver findings of investigation. CS and Investigator Ruben Munoz conducted investigation that included review of documentation, and confidential interviews. Based on the information obtained a preponderance of the evidence revealed this allegation is substantiated. This facility is being cited for violation of ILS Version 5 section 87072(c)(1) Personal Rights. Copy of this report, ILS Discrepancy, LIC Confidential Names, and LIC Appeal Rights left at the facility at conclusion of inspection. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Charles Kinney LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, E SHAW AVE This is an official report of an unannounced visit/investigation of a complaint received in our office on 12/05/2023 and conducted by Evaluator Charles Kinney PUBLICCOMPLAINT CONTROL NUMBER: 24-CR- FACILITY NAME:BRIGHTER HORIZON TREATMENT CENTERS, COTTONWOODFACILITY NUMBER: ADMINISTRATOR:DAVID VAYNTRUBFACILITY TYPE: ADDRESS: GRAYSTOKE WAYTELEPHONE: (323) 449- CITY:CLOVISSTATE: CAZIP CODE: CAPACITY:6CENSUS: 5DATE: 04/25/ UNANNOUNCEDTIME BEGAN: 01: PM MET WITH:William ZacharyTIME COMPLETED:02: PM 9Staff are physically abusing minor(s) in care. Staff member caused injury to minor in care. Staff member is distributing illegal substances while at the facility. Staff do not prevent minors from engaging in physical altercations with other minors while in care. INVESTIGATION FINDINGS: 13Complaint Specialist C.K. Kinney(CS) traveled to Brighter Horizons Treatment Center-Cottonwood and met with William Zachary to deliver findings of investigation. CS and Investigator Ruben Munoz conducted investigation that included review of documentation, and confidential interviews. Based on inconsistencies in the information obtained a preponderance of the evidence could not be obtained so these allegations are deemed Unsubstantiated. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Charles Kinney LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 2 of Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, E SHAW AVE FACILITY NAME: BRIGHTER HORIZON TREATMENT CENTERS, COTTONWOODFACILITY NUMBER: 107207215


raw_content:
Investigation Findings:
13Complaint Specialist C.K. Kinney(CS) traveled to Brighter Horizons Treatment Center-Cottonwood and met with William Zachary to deliver findings of investigation. CS conducted investigation that included review of documentation, and confidential interviews. Based on inconsistencies in the information obtained a preponderance of the evidence could not be obtained so these allegations are deemed Unsubstantiated. Copy of this report, LIC Confidential Names and LIC Appeal Rights left at facility at conclusion of inspection. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Charles Kinney 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


raw_content:
Investigation Findings:
13Complaint Specialist C.K. Kinney(CS) traveled to Brighter Horizons Treatment Center-Cottonwood and met with William Zachary to deliver findings of investigation. CS and Investigator Ruben Munoz conducted investigation that included review of documentation, and confidential interviews. Based on inconsistencies in the information obtained a preponderance of the evidence could not be obtained so these allegations are deemed Unsubstantiated. Copy of this report, LIC Confidential Names and LIC Appeal Rights left at facility at conclusion of inspection UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Charles Kinney 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


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Lisa Slusher traveled to Brighter Horizons Treatment Center-Cottonwood and met with Carolyn Ruffin to deliver findings of investigation. LPA Lisa Slusher conducted investigation that included review of documentation, and confidential interviews. Based on inconsistencies in the information obtained a preponderance of the evidence could not be obtained so these allegations are deemed Unsubstantiated. Copy of this report, LIC Confidential Names and LIC Appeal Rights left at facility at conclusion of inspection 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 1


summary: Complaint Investigation - Substantiated - 1 deficiency

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Lisa Slusher traveled to Brighter Horizons Treatment Center-Cottonwood and met with Administrator Caroline Ruffin to deliver findings of investigation. LPA Slusher conducted investigation that included review of documentation, and confidential interviews. Based on the information obtained a preponderance of the evidence revealed this allegation is substantiated. This facility is being cited for violation of ILS Version 5 section 87072(c)(1) Personal Rights. Copy of this report, ILS Discrepancy, LIC Confidential Names, civil penalty assessment and LIC Appeal Rights provided to Administrator at conclusion of inspection. SubstantiatedEstimated 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 Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE FACILITY NAME: BRIGHTER HORIZON TREATMENT CENTERS, COTTONWOODFACILITY NUMBER: 107207215

Deficiencies:
87077: (2)	Provision of an age-appropriate allowance to all children no less frequently than once per month.

met_with: Caroline Ruffin

title: Personal Services 		 (a)	The licensee shall ensure the following


raw_content:
Investigation Findings:
13On May 13 2024, Licensing Program Analyst (LPA), Lisa Slusher traveled to Brighter Horizon Treatment Center, Elm, Short-Term Residential Therapeutic Program located in Clovis, CA, to deliver the findings of a complaint investigation and met with Mao Lee Xiong and Anthony Williams. LPA conducted a confidential interviews, reviewed documentation, and obtained copies of pertinent documentation. Based on investigation conducted, the allegation is SUBSTANTIATED. Citations are issued for CCR title 22, General regulation section 80073 and 80074 and 87068.2. A copy of this report was provided to the facility at the conclusion of the inspection. SubstantiatedEstimated 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 Control Number 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE FACILITY NAME: BRIGHTER HORIZON TREATMENT CENTERS, COTTONWOODFACILITY NUMBER: 107207215

met_with: Mao Lee Xiong, Anthony Williams


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Lisa Slusher traveled to Brighter Horizons Treatment Center-Cottonwood and met with Mao Lee Xiong to deliver findings of investigation. LPA conducted investigation that included review of documentation, and confidential interviews. Based on inconsistencies in the information obtained a preponderance of the evidence could not be obtained so these allegations are deemed Unsubstantiated. Copy of this report left at facility at conclusion of inspection. 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 1

met_with: Mao Xiong


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analysts (LPAs), Lidia Tinoco and Vanessa Galvan conducted an unannounced visit to the Brighter Horizons Cottonwood STRTP in order to deliver the findings of the above allegations and met with Senior Facility Manager, Charles Paul and Senior Facility Manager, Zachary Williams. On March 13, 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: Charles Paul, Zachary Williams


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Les Inouye and Licensing Program Manager Lou Bartolome travelled to the facility listed above to conduct a prelicensing inspection. The Licensee currently holds two other STRTP licenses in Bakersfield. The application, Plan of Operation and Program statement are under review by SOC and CCL. The licensee will be provided corrections and a Technical Assistance video conference will be scheduled. 1. Facility Grounds are clean and free of debris or observable hazard. 2. Adequate indoor and outdoor activity space and materials observed. 3. Chemicals appropriately locked. 4. Centrally stored medications area observed, A lock will be installed to secure the area.. 5. First aid kit complete with appropriate manual observed. 6. Adequate storage space observed. 7. Individual beds in good repair observed, equipped with, clean mattresses and pillows observed. Individual beds were observed with appropriate clean linens in good repair. Adequate supply of additional bedding and linens observed. Mattresses/box spring on some beds need to be reviewed for proper comfort. 8. The house has 3 bedrooms, double occupancy located on the second floor level. Bedrooms are accommodating of all required furnishings. 9. Adequate food storage space observed. 10 .Dining room equipped with large table and chairs accommodating of all clients. 11 .Facility has 1 full bathroom in the house for client use, Master bed room bath is for assigned clients only. Both are operable. 12 .Facility has no pool. Public pool and club house is available. 13. No firearms or weapons are allowed in the facility. 14. Staff office is designated to be in the garage which has not been set up to date. Garage is secured with a lock. 15. Fire extinguishers and smoke/Co2 were observed.

met_with: Nikkia Moten


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Manager Lourey Bartolome(LPM) and Complaint Specialist C.K. Kinney(CS) traveled to the facility and met with Nikkia Moten to conduct pre-licensing inspection. CS and LPM toured the facility and observed the lock to the medication area has been installed and is functional. Also observed were locking boxes to be used for medications. Also noted was at least two of the client beds need mattresses. The current set up is a box spring and is very stiff. Location of Staff office for this facility will be discussed with Akila Crane. LPM and CS requested LIC Designation of Facility Responsibility and LIC Personnel Report be submitted by 01/03/2023 to LPA Les Inouye and LPM. No deficiencies observed or cited during this inspection. Corrections to be completed by 01/03/2023. Copy of this report left at facility at conclusion of inspection.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Manager (LPM) Lourey Bartolome and Licensing Program Analyst (LPA) Vanessa Galvan traveled to the facility and met with Nikkia Moten to conduct pre-licensing inspection. LPM conducted a Prelicensing inspection to verify that the items from the previous inspections have been addressed and corrected. Based on the inspection, LPM is recomending that the facility be provisionally licensed with the conditions that the Licensee continue to provide the required updates that are being requested by SOC and the LPA that is reviewing the application. Failure to meet the conditions can affect the licensing process. Prior to accepting any placements, all staff need to be fingerprint cleared and associated to the facility. Copy of this report was left at the facility at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On this date a case management inspection is completed by LPA Lisa Slusher. During this inspection, LPA discussed with facility an incident report including information regarding an incident on 6/4/2023. LPA advised the facility to submit an updated incident report including complete information regarding the incident and follow up actions by facility administration. The current report does not include information about a restraint or administrative follow up. A technical violation for STRTP interim licensing standards section 87061 is noted on this date.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, a meeting is held via the online Teams format. Present for Brighter Horizons are Irina Vayntrub, Nikkia Moton and Carolyn Ruffin. LPA (Licensing Program Analyst) Lisa Slusher and LPM (Licensing Program Manager) Lourey Bartolome are present for the CCLD. The purpose of this meeting is to follow up on a complaint, recent incidents at the facility and other items. LPA reviewed with the facility administration the status of the pending complaint, which will be closed with the administrator following this meeting. LPA further noted inconsistencies and a lack of information in incident reports submitted by the facility.

met_with: Irina Vayntrub, Nikkia Moton, Carolyn Ruffin