summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced collateral inspection on 6/9/22 at 9: AM to the administrative office located at Placerville Drive, Placerville to discuss incident reports. LPA discussed the following incident reports while at the administrative office: 9/13/ C1's bags were searched when returning from Golden Plaza but there is no indication as to probable cause that would warrant a search of belongings. LPA advised that this may be seen as a violation of client rights as search does not seem to be warranted. 9/16/ C1's room was searched and medications were found in a gum container. LPA questioned the medications found, how they were obtained or prescribed to C1. LPA also cautioned that the agency needs to articulate the permission requested and/or obtained for rooms searches and what the probable cause was that prompted the search. 11/16/ C2 was identified as being on "Safety Watch" and it is indicated that there were to be daily room searches due to this Safety Watch. LPA advised the agency that this cannot be a blanket policy. CEO states that this has been removed and now the policies when on a Safety Watch are individualized, spelled out in Needs and Services Plans and signed off by parent/guardian or child welfare. 2/15/ C3 has a history of going after their medications when the medications were passed. LPA questioned change in the procedures following an incident that took place a few months prior to this about lunging for medications. In addition, C3 was able to get medications and ingest an excessive amount of medications. C3 was transported to the hospital for further evaluation and released the next day back to the facility. 3/18/ C4 was on a "Heightened Supervision" and room search was conducted. LPA advised that being on a heightened supervision is not probable cause to warrant search of their room. CEO states that this is a term used to ensure that staff are increasing supervision of the youth due to recent incidents to more than what they normally did with the youth. LPA again advised the agency of the policy to conduct rooms searches cannot be simply because the youth is on "heightened supervision". 4/18/ C5 was restrained after making remarks about self harm by running into traffic. LPA advised the agency that the report does not articulate any eminent danger to youth or other youth in the facility and thereby this use of restraint may be an unauthorized restraint. LPA requested that the agency provide documentation of advisement to all staff about the items discussed and CEO states that she continues to work with staff on writing of incident reports to ensure that they are clear and concise and meet expectations per the Licensing standards. Also discussed during the inspection on this date was the licensing fees that are all confused and not appropriated correctly. LPA did advise that the agency provide details about the fee assessments via email so that discussion can be held with the Department's Accounting Unit to appropriate the fees paid appropriately. Exit interview conducted and documents provided.


state: CA

facility_name: SUMMITVIEW CHILD AND FAMILY SERVICES - LOTUS

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection to the administrative offices for Summitview on 10/12/23 at 12:00 noon and met with Haley Randle, Director of Youth Residential Programs. LPA Hill discussed incident reports with following incident reports with Danielle Bingle, administrator: * 8/10/ This report is related to C1 and C2 (see LIC811 dated 10/12/23) engaging in a behavior that may have been sexual between two youth but the report does not indicate that it was sexual in nature. Ms. Bingle states that it was reported by one of the youth as sexual. LPA Hill advised Ms. Bingle to put additional information in the reports to ensure that it is clear. * 8/1/ This report details an alleged sexual incident between C4 and C2 that was not consensual. LPA Hill advised the agency that this incident needs further investigation at this time. * 7/30/ This report is related to C3 (see LIC811 dated 10/12/23) speaking to individual(s) via phone of various ages. LPA Hill advised Alyson Chavez, Administrator, that this may not even be reportable unless there is some other inappropriate activity. * 7/25/ This report details that C4 engaged in property destruction by emptying out the refrigerator and breaking all contents of the containers. Ms. Chavez recalls that during this incident they ensured the safety of all the youth in the facility by having staff and clients to go another area until the area could be cleaned. * 7/22/ This report is related to C4 using C5's phone to order an Uber for an unauthorized absence. LPA Hill asked staff about observing C4 using C5's phone. Ms. Chavez recalls both youth were planning to leave but C5 was not fast enough to get to the vehicle and C4 left without waiting. Overall, LPA advised that the incident reporting is going well but did advise Ms. Chavez to provide additional information or explanation in the incident reports and particularly in the 24 hour reports. No citations were issued, exit interview was conducted and documentation was provided to Ms. Randle.

report_type: Facility Evaluation

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 2/8/24 at 12: PM and met with Haley Randle, Director of Youth Residential Programs, to discuss a serious incident. LPA Hill informed Ms. Randle that the circumstances surround an unauthorized absence for C1 and C2 (see LIC811 dated 2/8/24) are currently being looked at. The incident included two youth absconding from the facility at approximately 1: AM on 2/7/24. The facility was acutely aware that both youth were planning to leave the facility days prior and had implemented an additional staff in the facility in case this should happen. When this did happen, there was additional staff present (S1) that followed youth as they left. Unfortunately, S1 lost sight of the youth. Youth were found on 2/7/24 around noon and transported to the hospital. LPA Hill discussed with Ms. Randle the reporting requirement related to the 24 hour notice. LPA Hill informed Ms. Randle that while the Department appreciates the expeditious nature of the reporting by the agency, the agency should first pause to assess incidents that require 24 hour notification to ensure that accurate and thorough information is being provided. LPA Hill advised the agency to pause to get as much information as possible prior to sending the notification to Licensing. In this instance, the rush to get the notice to Licensing caused some confusion over additional information as it was trickling in. LPA Hill reminded Ms. Randle that it is more important to get accurate and thorough information rather than trying rush to get the 24 hour report to Licensing, possibly missing certain critical information. LPA Hill is looking further into this incident and shall return at a later date for additional interviews as necessary. LPA Hill did request the Needs and Services Plans for C1 and C2 and training for S1. End of document.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 5/16/24 at 11: AM and met with Haley Randle, Director of Youth Residential Programs. LPA Hill made the inspection to discuss an incident dated 5/9/24 where C1 (see LIC811 dated 5/16/24) discharged from a psychiatric hold and was prescribed a new medication. The new medication was sent to a local pharmacy but they did not have this medication in stock and it had to be ordered, rendering it not available until 5/10/24. C1 was not administered the medication the evening of 5/9/24 and 5/10/24. While this is not fault of the facility, LPA Hill did discuss with the facility the potential of obtaining a limited number of medications, one to two day's worth, while still at the hospital or other treatment facility that would allow the facility time to fill any prescriptions to avoid situations such as this in the future. When speaking with the therapist about this situation and C1's situation as a whole, therapist states that it is hard to depend on this for each type of hospitalization as each institution's policies and procedures could be different and/or preclude a policy such as this for discharges. LPA Hill obtained Needs and Services Plans for C1, along with C1's face sheet, Child & Family Team Meeting information, and other documentation relevant to C1's placement. No citations were issued during the inspection. Exit interview was conducted and document was provided to Ms. Randle.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 7/18/24 at 2: PM and initially met with Jose Navarrete, Residential Manager. Mr. Navarrete informed LPA Hill that the administrator of the home was present so LPA Hill worked with Administrator, Alyson Chavez. Mr. Navarrete signed documentation related to the inspection because Administrator Chavez needed to get to the residence. LPA Hill discussed the following incidents with Administrator Chavez: 7/2/24 - C1, C2 were escalated and C1 cause property damage and assaulted staff. Law enforcement was contacted and subsequent removed C1 for a mental health evaluation. C1 was able to commit to safety with the crisis worker and was returned to the facility. LPA Hill asked about an emergency CFT and citations/court date and was informed that while C1 was issued a citation, Administrator states that they do not feel that there will be a court date and feels that the charges will be dropped. Administrator states that they did a CFT following this incident and C1 was moved to another facility within the agency. No follow up is necessary and no citations were issued for this incident. 7/9/24 - C3 was not administered their PM medication on 7/8/24. Administrator states that there was a lot going on at the facility and it was an oversight of staff. Administrator states that they did counsel staff responsible and did provide a reminder to staff about the importance of the medication passing. No citations applicable and no further investigation needed. 7/13/24 - C4, C3, C5 were in one room together sleeping. C4 refused to listen to staff prompts to return to their own room for sleeping and fell asleep on the floor of the youths' room. Administrator states that staff were counseled about how to redirect youth. Administrator states that staff was provided additional training on how to properly deal with these situations. Administrator states C3 is no longer at the facility due to an unauthorized absence and C4 was relocated to another facility. C5 was a visiting youth and was only there for the weekend. Youth are no longer socialized due to noncompiance. No citations issued and no additional investigation needed. Exit interview conducted and documentation was provided.

met_with: Alyson Chavez, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Michelle Kyane conducted a case management inspection on 08/22/2024 based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 3 out of Direct Care Staff and 3 out of 4 youth files were reviewed. 2 out of Direct Care Staff and 0 out of 4 youth were interviewed. (See the Confidential Names List, LIC 811, August 22nd, 2024). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth case plans, quarterly assessments, and crisis intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Michelle Kyane observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Alyson Chavez.

met_with: Alyson Chavez


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection to the administrative offices on 8/23/24 at 2: PM and met with Jose Navarrete, Residential Director. LPA Hill made the case management inspection to discuss an incident dated 8/19/24 that allegedly took placed while C1 (see LIC811 dated 8/23/24) was attending schooling and groups at another house within this agency during schooling hours. LPA Hill spoke with Mr. Navarrete and staff Danielle Bingel during the inspection on this date and was informed that C1 is currently under mental health evaluation at a local hospital and unable to be interviewed. LPA Hill obtained other incidents involving C1 since this incident and information about the staff person to whom the disclosure was made. LPA Hill will evaluate information received for further investigation. Exit interview conducted and documentation was provided during today's inspection.

met_with: Jose Navarrete, Residential Director


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Tamara Hill and Brittany Crass made an unannounced annual inspection on 8/28/24 at 9:20 am. LPA Hill arrived and maintenance were at the home making repairs as a result of an incident that took place at the facility the night prior. LPA Hill alerted Haley Randle, Director of Youth Residential Programs of LPA's arrival and Ms. Randle came to the facility to assist in the inspection. LPAs Hill and Crass conducted a physical plant inspection of the facility inside and out and observed the following: There are five youth in the facility. LPAs observed that there are three dual occupancy rooms that are equipped with bedding, storage, dressers and closets. There are two client bathrooms that have hot water that meets requirements, water measuring at 116 degrees Fahrenheit, toilets flush and showers working. Paper towels and toilet paper are present in the bathrooms for client use. LPAs observed that while chemicals in the garage are locked and not accessible to youth, LPA advised that the facility lock chemicals in an additional locking cabinet for the safety of the youth that may accompany staff into the garage for any reason. The facility has operable smoke and a carbon monoxide detector in the hallway but it was not operating initially during the inspection. Maintenance was on site and batteries were replaced. It was operable by the end of the inspection. LPA observed that there is fence not attached during the physical plant inspection. LPA did advise that this needs to be attached as this is light enough to be picked up by youth and/or used as a weapon. LPA observed that all seatbelts were functioning, the vehicle had valid registration and proof of insurance in the vehicle and the vehicle started and runs. LPA observed that one of the screens was on the ground outside the window and advised that it be placed back in its place. Fire extinguisher was mounted on the wall near the kitchen and was last inspected on 7/30/24. While there are no youth at the facility at the time of the inspection, they are in school at another location at the time of the inspection. LPAs advised that they would be going to that location to conduct interviews with staff and clients. LPAs also advised that additional inspection will occur on another undisclosed date to include inspection of the youth and staff records. LPAs issued advisories for Outdoor Activity Space and Buildings and Grounds. Exit interview conducted and documents provided. End of inspection on this date.

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Tamara Hill and Brittany Crass made an unannounced Case Management - Annual Continuation inspection on 8/29/24 at 9:45 and met with Haley Randle, Director of Youth Residential Programs to conduct review of the staff and client records. LPAs Hill and Crass reviewed staff and client records during the inspection and observed the following issues as it relates to the record review of the staff and client records: Records reviewed included two staff persons and two youths in care, Emergency Interventions and Emergency Intervention Log, Disaster Preparedness and Drills, and Core Therapeutic Services. The Emergency Intervention Log does not have the outcome of the licensee's review of emergency interventions when used in the facility. As a result of this, the facility was cited for 87095.61(g)(6) Documentation and Reporting Requirements as documenting the outcomes of restraints is required. LPAs issued a Technical Advisory indicating that the agency must maintain the educational qualifications of applicants via transcripts and/or degrees as applicable for staff. No other citations were issued on this date.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 9/6/24 at 11: AM and met with Haley Randle, Director of Youth Residential Programs. LPA Hill made this inspection to discuss the finalizing of an open case management inspection initiated on 8/23/24, regarding a youth allegedly finding a pill on the ground. LPA Hill interviewed staff supervising youth during the time that the alleged incident was to have happened and it was determined that it was not possible as staff was supervising youth and was with youth in crisis at the time of the alleged incident. Further discussion with Ms. Randle revealed that youth was supervised the entire time they were outside and in the house when this allegedly happened. LPA Hill was not able to interview youth in question as youth has been hospitalized since this incident and subsequently removed from the facility due to safety of the youths in the facility. This concludes the investigation related to this incident. LPA Hill also discussed the results of the annual inspection conducted 8/28/24. During interviews with youth and staff, LPA Hill was made aware that youth are not happy with the lunches provided in that they indicated that it's "always a sandwich" consisting of "bagels and cream cheese". LPA Hill advised Ms. Randle that when meals are provided by the facility, they need to have acceptable alternatives so that youth have a choice if they do not like or do not want what is prepared. Ms. Randle indicated that youth can request alternatives to the lunches provided. LPA Hill informed Ms. Randle that this was not indicated in the interviews conducted with staff or youth in care. LPA Hill also discussed outings with Ms. Randle in that it was discussed that if youth do not want to attend a planned outing, they are given consequences, including a frozen program, which includes youth having to be in their room the duration of the outing but allowed out of their room for fifteen minutes of each hour. LPA Hill advised Ms. Randle that youth cannot be given consequences if they choose to not participate in outings. LPA Hill also discussed with Ms. Randle a denied exemption for S1. Ms. Randle indicated that the agency utilizes S1 for groups related to substance use and abuse. During the inspection, Anna Gleason, CEO, was contacted and indicated that it is their intent is to sponsor this individual in receiving an exemption with the Department. In the mean time, S1 was fingerprint cleared via "Accurate", which is utilized by the agency for fingerprinting services for staff employed by the agency for services other than in residence working with youth in care. Some of these services include their Wellness Team (therapists, family specialists, and other school based services), and Outpatient Support. The agency is contracted to provide mental health services to youth in the surrounding school districts. No citations were issued related to this issue. Exit interview was conducted and documentation was provided to Ms. Randle.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Suzanne Martinez conducted a case management inspection on July 23, 2025 at 8: AM based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 5 out of Direct Care Staff and 6 out of 6 youth files were reviewed. 2 out of Direct Care Staff and 2 out of 6 youths were interviewed. (See the Confidential Names List, LIC 811 (July 23, 2025). The Plan of Operation including policies and procedures were reviewed. Minutes from the Board of Directors' meetings related to the facility's incidents involving contact with law enforcement were emailed and reviewed. Based on the analysis of the confidential interviews and youth files review including the Needs and Service Assessments, Safety Plan, Risk Assessment and Treatment Plan, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Martinez observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Director of Youth Residential Programs, Haley Randle.

met_with: Haley Randle, Director of Youth Residential Programs


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Aleza Ruiz conducted an unannounced case management inspection on 11/20/25 at 2: PM regarding an incident report dated 11/03/2025 that involved a youth being given two 10 mg medications rather than their prescribed 20 mg dosage. LPA met with Anna Gleason, CEO regarding the incident report and requested the staff schedule for the month of November within the facility, LIC 500 with staff contact information and medication logs for the past 30 days. No citations were given on this date. Further investigation is needed. A signed copy of this LIC-809 report was provided to Anna Gleason, CEO. An exit interview was conducted.

met_with: Anna Gleason, CEO


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Aleza Ruiz conducted an unannounced case management inspection on 11/21/25 at 10: AM to continue follow up regarding a prior case management on 11/20/2025. LPA interviewed one youth at the facility regarding the incident report received by department. No citations were given on this date. Further investigation is needed. A signed copy of this LIC-809 report was provided to Anna Gleason, CEO. An exit interview was conducted.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Jean Stidman and Sarina Buchannan on 12/03/25 at 9: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs Stidman and Buchannan met with Haley Randle, Director of Youth Residential Programs, and Jessica Maglietta, Administrator, and inspected the facility inside and out. LPA reviewed one child's record and five staff personnel files on site at the facility. LPA reviewed one child's psychotropic medications and medication records. LPA interviewed three staff on site to discuss the facilities policies and procedures of operation. LPA interviewed one child currently prescribed psychotropic medication. LPA provided a copy of this licensing report to Jessica Maglietta, Administrator. No deficiencies are being cited at this time. LPA conducted exit interview with Jessica Maglietta, Administrator.

met_with: Jessica Maglietta, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 10/9/ Licensing Program Analyst (LPA) Jean Stidman arrived unannounced at 1:30pm and met with Anna Gleason, CEO for the purpose of a case management inspection. On 7/25/25 during inspection of the facility and interview with Anna Gleason Chief Executive Officer (CEO), it was observed that two siblings of opposite genders, ages 17 and 12 are sharing a room. This is a violation of the Short-Term Residential Therapeutic Program Interim Licensing Standards (ILS) version 5 regulation 87087(b)(3)(C) Buildings and Grounds. The facility is being cited for violation of the Short-Term Residential Therapeutic Program Interim Licensing Standards (ILS) version 5, regulation 87087(b)(3)(C) Buildings and Grounds due to two siblings that identify as their birth genders.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Aleza Ruiz arrived unannounced at the facility for the purpose of completing a case management regarding three incident reports received by licensing involving medication errors. LPA met with Haley Randle, Director of Residential Programs to discuss the medication errors and was provided with contact information of staff that are not currently present at the facility. LPA interviewed two youth regarding the incidents. Further investigation for two out of the three incident reports will be necessary as staff were not present to interview. No citations were given on this date. This document has been provided to the licensee.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 5/25/23 at 2: PM and met with Anna Gleason, CEO and Jose Navarrete, Administrator, to discuss incident reports LPA Hill informed Mr. Navarrete that the following incident reports were of concerns and for the following reasons: * 5/8/ C1 (see LIC811 dated 5/25/23) assaulted C2 and in the incident report, there is no mention of a safety assessment being done for the youth to ensure that they could remain roommates after the incident. * 5/13/ C2 and C3 youth left the facility on two different unauthorized absences and on the second one, it indicates that when youth returned to the facility, they showered and went to bed. The time youth left was 5: PM but there is no mention on what time they returned to the facility. * 5/15/ Incident report has only initials for all staff and clients. LPA Hill requested the full report to be provided without initials. This incident also indicates that C4 was not provided their medication prior to eating as prescribed. LPA Hill requested proof that staff was provided with the re-training as indicated on the report. In addition, LPA Hill requested going forward that the name of the staff be revealed in medication errors, date of the re-training as this needs to be completed immediately, and date of the write up as applicable. LPA Hill requested that this incident report be updated with the requested information. * 5/23/23 the facility had another medication error for C4 in which C4 was given a double dosage of their medication. The report does indicate that the facility called poison control but the date of the "written warning" or name of the staff was not provided. LPA Hill requested that this incident report be updated with the requested information. Facility was cited for 80075(b) Health Related Services. Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. C4 was administered double the medication that was prescribed on 5/23/23 which is a potential risk to the health, safety or personal rights of youth in care. Exit interview was conducted and documentation provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA ) Tamara Hill made an unannounced case management inspection on 4/16/24 at 2: PM and met with Haley Randle, Director of Youth Residential Programs to discuss some issues related to a recent complaint investigation. Recent complaint investigation included review of documentation related to bed checks. The documentation obtained indicated that S1 did not conduct the required bed checks per the agency's policy. However, when interviewed, S1 indicated that the required bed checks were conducted despite the documentation indicating otherwise. S1 went on to sat that if the required bed checks had not been completed, S1's supervisor would have observed this via the video camera review and addressed it with S1 but this had not happened. LPA Hill reminded the facility that documentation is key to compliance and part of their Program Statement, in that their program statement indicates that they are to document the bed checks every 15 minutes. As such, LPA Hill issued a Technical Violation (TV) regarding the need to document bed checks per the agency's program statement. LPA Hill also discussed internal investigations with the agency as it pertains to their responsibility to investigate allegations or issues alleged by clients in care and take appropriate actions based on those allegation(s) to ensure the safety of all youth in care. Investigation indicates that during confidential interview(s), "failed to thoroughly document and follow up with the status or completion of [an] internal review of the incident". LPA Hill informed the agency that these report(s) if not investigated by Community Care Licensing via a complaint or case management inspection, is the responsibility of the agency to investigate and follow through with any/all appropriate actions to ensure the health, safety and personal rights of all clients in care. This advisory was also included on the Technical Violation (TV) indicated above as the agency's program statement indicates that they will investigate and/all allegation(s) and take appropriate actions to protect the health and safety of all youth in care. Lastly, interviews conducted for a complaint investigation revealed some issues or potential violations observed. The first is related to the facility's obligation surrounding room compatibility. Per Interim Licensing Standards, Version 4, Buildings and Grounds, Section 87087(e), the licensee is required to document bedroom sharing arrangements ensures the health and safety of each child. In the case involving C1 and C2, investigation indicated that even after a reported disclosure of inappropriate touching between C1 and C2, the youth continued to be roommates for 11 weeks following the disclosure. This is a violation of the youths' rights to be in a safe and healthy environment. Facility was cited for violation of Personal Rights, 87072(c) including the right to live in a safe, healthy and comfortable home. Despite knowing that the youth were no longer compatible due to the allegation, the facility did not move the youth to another room or facility. Exit interview was conducted and documentation was provided to Ms. Randle along with appeal rights.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill conducted an unannounced case management inspection on 8/16/24 at 11: AM and met with Jose Navarrete, Residential Manager. LPA Hill conducted the inspection on this date as a follow up regarding an incident report dated 8/9/24 where C1 (see LIC811 dated 8/16/24) went on a home visit with family and was not provided their medications to take with them. LPA Hill questioned Mr. Navarrete regarding the staff who neglected to provide the medications and what the recourse for them not sending the medications as required. Mr. Navarrete states that it appears from the facility's documentation that these three staff (S1, S2, S3) were not given a corrective action, nor was there additional training provided to ensure that this does not happen in the future. LPA Hill advised Mr. Navarrete that because the facility failed to ensure that staff were provided training or counseled about this error, the facility will be cited for Title Regulations, Section 80075(b) Health Related Services as the facility is responsible for ensuring that medications are given to youth as prescribed. When youth left the facility on an authorized home visit, the staff did not provide the medications to the parent or guardian to ensure that medications were administered during the youth's home visit. LPA Hill provided the documentation and appeal rights to Mr. Navarrete.

met_with: Jose Navarrete, Residential Manager


summary: Facility Evaluation

raw_content:
Narrative:
An announced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Connie Goldie on 08/21/2024 at 09: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Goldie met with Haley Randle, Director of Youth Residential Programs to review staff and client files at the Administrative office. LPA Goldie met with Alyson Chavez , Administrator who assisted with the inspection at the facility. LPA inspected the facility inside and out. LPA reviewed one child's record electronically. LPA reviewed three staff personnel files at the administrative office. LPA reviewed one child's psychotropic medications and medication records. LPA interviewed three staff on site to discuss the facilities policies and procedures of operation. LPA interviewed one child currently prescribed psychotropic medication. LPA provided one technical violation. This is not a deficiency. During the inspection the LPA observed one type B deficiency (see attached LIC809D). LPA Goldie cited Interim Licensing Standards Needs and Services Plan 87068.2(g). Plan of corrections were discussed and appeal rights were provided. LPA provided a copy of this licensing report to Alyson Chavez , Program Administrator.

met_with: Hayley Randall Director of Youth Residential Programs Alyson Chavez Administrator


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
not communicating with authorized representative about incidents that lead to C1 missing appointment(s) until C1 was discharged from the facility. When interviewed, the authorized representative stated that the communication received was after C1 had already left the facility and that it was that C1 had an orthodontic appointment that had to be rescheduled twice due to behaviors. Authorized representative states that they had conducted two Child and Family Team (CFT) meetings while C1 was in the facility but that this was never brought up or discussed during those meetings. Authorized representative states that had this information been shared prior to discharge, the authorized representative could have made additional visits to the facility to assist in the transport to the necessary appointment(s) or stabilization of C1's placement prior to C1 being displaced. When LPA Hill interviewed agency staff, LPA Hill learned that there is no specific documentation or policy related to appointments made or cancelled for clients. Since this complaint investigation, they have now implemented procedures for documenting appointments made, reasons for cancellation when necessary, and notifications to placing agencies. As a result of the investigation, documents obtained and interviews conducted, the allegation that staff did not communicate with minor's responsible party [about the missed appointments] is SUBSTANTIATED meaning that the "preponderance of the evidence" standard has been met. Facility was cited for violation of Reporting Requirements, 80061(f) as the facility is required to make report(s) to the client's authorized representative of incidents, including but not limited to any unusual incident which threatens the physical or emotional health or safety of any client. LPA Hill observed that the facility did not provide C1's authorized representative information including the need to cancel medical, dental, and vision appointments as a result of behaviors. Exit interview conducted and documentation provided. requirement that the facility obtain a written medical assessment of clients admitted "prior to or within 30 calendar days following [their] acceptance". Complaint also alleges that C1 was not taken or provided access to dental or vision services. When reviewing the documentation related to C1, there is documentation that a physical was completed, by the placing agency, the week prior to placement. Related to dental services, it is documented that C1 had two appointments for orthodontia care but those appointments were cancelled due to unsafe behaviors. There is no documentation related to vision services being provided but the regulations do not speak to time frames for this to be conducted and C1 was in the facility for a month. As a result of the investigation, documents received, and interviews conducted the allegation that the facility did not ensure that C1 attended scheduled appointments is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Documentation was provided to the facility along with appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 7/20/23 at 1: PM and met with Jose Navarrete, Residential Manager to discuss the complaint allegations. LPA Hill informed Mr. Navarrete that the complaint inspection included an initial complaint inspection at the facility on 5/12/23. Interviews were conducted with reporting party, authorized representative, and administrator. LPA Hill also obtained communications between the agency and C1's (see LIC811 dated 7/20/23) authorized representative. LPA Hill obtained agency's internal daily communications related to C1 and their stay at the facility. LPA Hill received C1's placement paperwork, medication and other medical-related documentation, Needs and Services Plan, and incident reports. The allegation that staff did not communicate with minor's authorized representative is related to the agency SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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 CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: SUMMITVIEW CHILD AND FAMILY SERVICES - AGAPEFACILITY NUMBER: VISIT DATE: 07/20/2023

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

report_type: Complaint Investigation

complaint_status: unsubstantiated


summary: Complaint Investigation - Unsubstantiated

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Narrative:
LPA Hill interviewed three youth and the administrator about the air conditioning unit being in disrepair and the comfortable environment for the youth. During interviews, it was indicated that the facility did contact an outside vendor to service the unit once it was noted on 8/9/23 that it was not functioning. The vendor came to the facility on 8/14/23 and 8/15/23, repairing it, but it stopped functioning again within 48 hours. The same vendor was asked to return to the facility on 8/17/23 and determined that a part needed to be replaced, but that it would take a few days for the part to come in. Final repair of the air condition unit was conducted on 8/22/23. During the time that the air conditioning unit was not functioning properly, the agency did supply the facility with an industrial-sized swamp cooler and fans for the youths' rooms to use during this time. The youth were offered to relocate to the administrative offices during this time but declined this option as they preferred to be in the facility where their bed and belongings were at. In addition, the agency provided LPA Hill with an invoice indicating annual maintenance with the same vendor dated July 13, 2022. Interviews conducted with staff and youth, indicated that while it was hot with the air conditioning unit not functioning, the agency did accommodate youth as best as possible by providing fans and an industrial-sized portable air conditioning unit in the facility until the necessary repairs could be completed. In addition, the agency offered to relocate youth temporarily to the administrative offices until the unit could be repaired but the youth opted to stay in the facility instead. As a result of the information obtained, documentation provided, and interviews conducted, the allegation that the facility air conditioning unit is in disrepair and that staff are not providing a comfortable environment for minors is UNSUBSTANTIATED meaning the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred as the agency made attempts to get a vendor to the facility for repair of the air conditioning unit and did attempt to make youth more comfortable by relocating youth to the agency's administrative offices while waiting for the unit to be repaired. Exit interview conducted and documents were provided to Ms. Randle.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 1/31/24 at 2: PM and met with Haley Randle, Director of Youth Residential Programs to discuss the findings for this complaint investigation. LPA Hill informed Ms. Randle that the complaint investigation included an initial physical plant inspection at the facility on 8/23/23 where it was observed that the facility was cool, air conditioning was working, and that the facility was neat and clean during the inspection. LPA Hill obtained documentation related to the air conditioning issue at the facility, including messages and discussions between staff about the excessive heat in the facility. LPA Hill also obtained a copies of invoices related to services conducted on 8/14/23 and 8/15/23 by an outside vendor. When the air conditioning unit stopped working a day later, the vendor returned to the facility, 8/17/23 and informed the agency that additional repairs were needed. The invoice indicates that the vendor finally completed the repairs for the air conditioning unit on 8/22/23. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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 SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: SUMMITVIEW CHILD AND FAMILY SERVICES - AGAPEFACILITY NUMBER: VISIT DATE: 01/31/2024


summary: Complaint Investigation - Substantiated - 1 allegation

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Narrative:
the agency's school site, the explicit conversation about the male genitalia continued with S2 and with other youth present. This resulted in another youth knowing what photo was, without having seen the photo. During confidential interviews, it was indicated to be common knowledge for S1 to talk about inappropriate topics while in the classroom with youth present. As a result of the investigation conducted and confidential interviews conducted, the allegation that staff exposed minor to photos of nude adults is SUBSTANTIATED at this time, meaning the "preponderance of the evidence" standard has been met. The facility was cited for violation of Short Term Residential Therapeutic Programs, Interim Licensing Standards, Version 5, Section 87072(a) Personal Rights as youth have the right to be free from physical, sexual, emotional, or other abuse...given the photograph was that of male genitalia, this is a violation of those rights. Exit interview was conducted with Ms. Randle and documentation, along with appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 2/8/24 at 12: PM and met with Haley Randle, Director of Youth Residential Programs to discuss the complaint finding for the allegation noted. LPA Hill informed Ms. Randle that the investigation included an initial inspection on 10/6/23 where documentation was gathered. Investigation was conducted by the Department's Investigations Branch, specifically Investigator Melissa Weaver. Included in the investigation were interviews with C1 (see LIC811 dated 2/8/24), C2, S1, S2 and in collaboration with the El Dorado County Sheriff's Office. In addition, photos related to this allegation were obtained from Summitview Child and Family Services. The allegation is related to an incident where S1 showed an inappropriate picture of male genitalia to C1. Confidential interviews indicated that S1 did show these photos to youth and when S1 and youth arrived at SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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 SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: SUMMITVIEW CHILD AND FAMILY SERVICES - AGAPEFACILITY NUMBER: VISIT DATE: 02/08/2024

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

complaint_status: SUBSTANTIATED


facility_name: SUMMITVIEW CHILD AND FAMILY SERVICES - AGAPE

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Narrative:
Investigation showed that maintenance was alerted to a possible incontinent issue in one of the facilities with youths beds prompting an agency-wide inspection which included all facilities operated by the Summitview Child & Family Agency. As a result of this inspection, mattresses were replaced if they were identified as soiled, stained, or showing signs of wear. It was alleged that one of the youth had removed the mattress cover after having an accident without telling staff so a new cover was not placed on the bed to prevent the soiling of the mattress. Staff interviewed indicated that the agency did an inspection of all the facility beds throughout the agency and replaced multiple mattresses throughout their facilities including the youth(s) who were identified as having incontinence issues. As a result of the investigation and interviews conducted, the allegation that youth was not provided with a mattress in good condition is SUBSTANTIATED at this time meaning the "preponderance of the evidence" standard has been met. The facility was cited for Short Term Residential Therapeutic Program, Interim Licensing Standards Section 87088(c)(1) Fixtures, Furniture, Equipment, and Supplies as the licensee is to provide and make readily available to each child an individual bed maintained in good repair; equipped with good springs and a clean mattress and investigation showed that one or more youth had been sleeping on a mattress that was soiled or mattresses that were identified as soiled or in need of being replaced as they did not meet this standard. Exit interview was conducted with Ms. Randle and documentation, including personal rights were provided. odor present as a result of the youths' incontinent issues, staff were cleaning the youths' rooms, doing the youths' laundry daily, and working with both youths on this issue in private so as to rid the facility of the smell. Interviews indicated that while it was difficult due to youths' behaviors of hiding clothes or not wanting to tell staff when there was an issue when youths' first arrived at the facility, staff tried. None of the staff and clients interviewed felt that staff were neglectful or dismissive of the issue and did take the youths' health and cleanliness issues seriously. As a result of this, while there was a smell that lasted in the house for about a month, the staff were working with youths in care to overcome the issues for a clean and safe environment for all in the facility. As a result of the investigation and interviews conducted, the allegations that licensee did not properly address minor's incontinence needs and did not ensure that the facility was kept odor free are UNSUBSTANTIATED at this time meaning that the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. The allegation that a youth is engaging in a relationship with an adult is related to a youth talking with an adult male while at the facility via a tablet furnished by Summitview Child and Family Services. During interviews, when it was discovered that youth was initiating conversations with this adult male. Subsequently, the tablet was removed and cleaned by the agency's technology department followed by firewalls being installed to prevent further contact with this individual. While the agency cannot prohibit calls due to youth's personal rights, the agency did discuss this further during youth's Child and Family Team meetings and is no longer a concern. As a result of the investigation and interviews conducted, the allegation that youth is engaging in a relationship with an adult is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with Ms. Randle and documents provided, including personal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 2/8/24 at 12: PM and met with Haley Randle, Director of Youth Residential Programs to discuss the complaint allegation. LPA Hill informed Ms. Randle that the investigation included an initial physical plant inspection at the facility on 10/20/23 with a collateral inspection conducted at the administrative offices for Summitview Child and Family Services as well. Subsequent collateral inspections to interview staff and clients were conducted on 12/15/23 and 1/31/24 where eight youth and seven staff were interviewed in total. The allegation that the licensee did not provide minor with a mattress in good condition is related to one or more mattresses being soiled due to an incontinent issue with one of the youths in care. During an agency initiated inspection conducted in October 2023, it was noted by agency staff that there were mattresses showing signs of wear and/or stained/soiled and the agency replaced identified mattresses for youth in care. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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 SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: SUMMITVIEW CHILD & FAMILY SERVICES - SUGAR PINEFACILITY NUMBER: VISIT DATE: 02/08/2024

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


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Narrative:
medical condition. Some of the recommendations on the documentation include the need to make lifestyle changes, including a healthy diet, an avoidance of processed foods and foods high in refined sugars and carbohydrates, and regular exercise. In addition, the paperwork indicates that the doctor recommended allowing youth to work with staff in selecting food choices for the shopping list and "snack box" at the facility that were conducive to youth's medical diagnosis. When interviewed, C1 indicated that initially the facility did not cater to C1's medical condition and options for snacks in the facility included inappropriate choices such as crackers and cups of noodles. C1 indicated that when C1's medical condition escalated and became emergent, then the facility began to work with youth on food choices, but this did not happen until C1 was about to leave and go home. Interviews conducted indicated that when the doctor provided suggestions on eating and logging food intake, they worked with youth to ensure doctor-recommended snack options were available and that food alternatives were offered including wheat bread versus white bread, wheat pasta versus bleached pasta, etc. LPA Hill requested copies of the menus for the facility from August 2023 to December 2023, that do not indicate alternatives as suggested or required by the doctor. The menu shows many food items specifically listed on the food avoidances list provided by the doctor. While substitutions may have been provided, there is no evidence that this happened as the menus provided do not indicate substitutes for items such as pancakes, sliders, sugary cereals, toast, rice, spaghetti, hamburgers (buns), baked potatoes, etc. to name a few. As a result of the information and documentation received, the allegation that the facility did not follow the doctor's orders is SUBSTANTIATED meaning the preponderance of evidence standard has been met. The facility was cited per Interim Licensing Standards, Section 87076(d) Food Services as food served shall meet special dietary needs...as recommended by a physician. The allegation that the facility leaves sharp objects accessible to clients in care is related to an incident where C1 had access to sharp objects and being able to access these sharp items without staff knowledge. LPA Hill observed an incident on or about 10/4/23, facility staff did not lock a staff drawer containing sharp items, including scissors, resulting in C1 accessing the drawer and getting some scissors without staff knowing. C1 then took the scissors into the bathroom during their shower time and cut their own hair without staff knowledge and without parental permission. While interviews indicated that the drawer was to remain locked, it was indicated that youth knew when staff neglected to lock the drawer as required. As a result of the information and documentation received, the allegation that the facility left sharp objects accessible to clients in care is SUBSTANTIATED meaning the preponderance of evidence standard has been met. The facility was cited per General Licensing Standards, Title Regulations, Section 80087(g)(1) Buildings and Grounds as dangerous items were not locked as required. The allegation that the facility is not conducting child and family team meetings (CFTs) as required is related to C1 not having the CFTs every 30 days as required by regulation. The reporting party states that while in care, the facility failed to conduct the required monthly Child and Family Team (CFT) meetings for this facility type of facility. During the investigation into these allegations, LPA Hill learned that C1 was initially placed into a different facility type with the same agency in April 2023. The licensee was informed that C1 required a Short Term Therapeutic Residential Program (STRTP) where the expectations and requirements were different. C1 was placed in the STRTP on 8/24/23, and a documented CFT meeting was conducted on 11/8/23. C1 was discharged from the facility 12/21/23. During this time, only one documented CFT was conducted, and no Needs and Services Plan was obtained for C1 from 8/24/23 to 12/21/23. As a result of the information and documentation received, the allegation that the facility is not conducting child and family team meetings (CFTs) as required is SUBSTANTIATED meaning the preponderance of evidence standard has been met. While regulations do not require a CFT every thirty days, the Needs and Services Plan are required to be updated every 30 days and shall consider recommendations of the child and family team, eluding to the requirement to have CFTs every 30 days. The facility was cited per the Interim Licensing Standards, Section 87068.3(b)(2) Modifications to the Needs and Services Plan. The allegation that the facility did not assist with discharge and aftercare services planning as required is related to C1 being discharged back to the care of their family with no aftercare services in place and no plan to continue to see youth until youth could get established with another provider for mental health services. The reporting party states that because C1 is a post adoption youth, they were informed that it was the family's responsibility to coordinate and look for services for C1 for ongoing mental health services after leaving placement because they lived so far away from the placement agency. When questioned, LPA Hill was informed that the therapist is responsible for postdischarge services for youth leaving care. When asked for proof of aftercare services coordination for C1, LPA Hill was informed that there were no aftercare services provided or coordinated for C1. Additional documentation provided shows there was a lack of communication with the Health Services Department within Summitview "on several things related to [C1's] health". As a result of the information and documentation received, the allegation that the facility did not assist with discharge and aftercare services planning as required is SUBSTANTIATED meaning the preponderance of evidence standard has been met. The facility was cited per the Interim Licensing Standards, Section 87089.1(d)(3) Mental Health as the facility shall ensure continuity of care, services, and treatment as a child moves from their short-term residential therapeutic program placement to home-based family care for at least six months postdischarge from a short-term residential therapeutic program. In this case, C1 went home without the required array of services as required. Exit interview was conducted with Ms. Randle and documentation was provided including appeal rights. indicated that they have asked for additional training related to good choices and getting C1 engaged in making healthy choices. C1 tends to refuse these services. Food shoppers were given healthy alternatives to purchase to have on hand for the house but cannot force youth to make those healthy choices. Regarding the allegation that the facility is threatening C1 with discharge is related to C1 needing to go to the emergency room due to their health condition and the facility informing the reporting party that if C1 were to go and be formally diagnosed with a medical condition that they could not handle or may not be able to accommodate, C1 would be discharged from the program. In speaking with the staff that regularly interacted with the reporting party and Chief Executive Officer, it was denied that C1 was ever threatened with discharge from the facility for diagnosis of this medical condition. The allegation that facility staff were discussing employment and/or discipline topics with youth in care is related to staff complaining about specific aspects of their employment with youth in care or where youth could hear these discussions. Staff were discussing topics such as not being paid enough to deal with youth, that staff are leaving their jobs to find employment that pays more, or being written up for things that youth do, and other personnel issues around youth in care. LPA Hill obtained proof of the facility's knowledge that at least one staff member was doing this via an email dated 10/19/23 to that staff person identifying that this is an issue when youth are present. In addition, there were multiple notices for staff about discussions in front of youth in care including 3/30/22, 8/17/23, 11/9/23 and 1/31/24. While this was happening at the agency, it was addressed, staff were counseled/reminded that this is not an acceptable practice. LPA Hill did not find additional personnel speaking about personnel issues around youth in care following the email reminder to not discuss personnel issues or other inappropriate topics in the facility. The allegation that staff did not appropriately intervene in adult/child interactions is related to an interaction that C1 had with outside medical personnel during a routine medical appointment. It was alleged that C1 reported that the interaction was a "deep conversation" with the medical personnel individual and may have been inappropriate as it was related to what drugs do to the brain. When interviewed, staff indicated that they would not always stop those conversations as youth benefit from hearing the same message from multiple individuals, not just the facility staff. Staff indicated that these messages go further when heard from multiple different sources. When interviewed, C1 indicated that staff accompanied C1 during the entire time of the appointments. During interviews, staff indicated that they would not intervene unless youth are having inappropriate conversations about the benefits of illicit drug use or how to obtain or use drugs. Staff indicated that the transport never reported an inappropriate conversation during a medical appointment, indicating that staff did not feel any conversations had been inappropriate. As a result of the investigation, interviews conducted, and documentation reviewed, the allegations that the facility did not meet the need of C1 as it relates to C1's health condition, the facility threatened to discharge C1, facility staff discussed employment and/or discipline topics with youth in care and facility staff did not appropriately intervene in adult/child interactions are all UNSUBSTANTIATED at this time meaning the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview was conducted with Ms. Randle and documentation, along with appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 3/21/24 at 10: AM and met with Haley Randle, Director of Youth Residential Programs to discuss complaint findings. LPA Hill explained the complaint allegations to Ms. Randle that investigation included an initial inspection to the facility on 11/8/23 and interviews with seven clients from and five staff, including the agency Chief Executive Officer (CEO) from 11/8/23 through 3/20/24. LPA Hill obtained documentation from the Director of Youth Residential Programs and CEO regarding C1 (see LIC811 dated 3/21/24). The allegation that the facility did not follow the doctor's orders is related to C1's medical condition needing specific food items and/or alternatives. When interviewed, the reporting party stated that the facility did not follow the doctor's orders in that they provided food choices in the home that were contrary to dietary recommendations based on C1's medical condition. In review of the documentation received from the facility, it was noted on medical paperwork that a care plan was developed on 10/20/23 to assist in managing C1's SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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 SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: SUMMITVIEW CHILD & FAMILY SERVICES - SUGAR PINEFACILITY NUMBER: VISIT DATE: 03/21/2024

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


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Narrative:
When arriving at the nonpublic site, S1 and C1 got into S1's vehicle and C1 observed S1's vaping device in the vehicle. S1 admits that the vaping device was in plain sight in the vehicle but that they put the device away immediately upon getting into the vehicle but that C1 had already seen it. Confidential interviews indicate conflicting statements as to whether or not S1 allowed C1 to use their vaping device during the transport. As a result of the information obtained and interviews conducted, the allegation that staff allowed a youth to smoke in staff's personal vehicle is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. The allegation that staff disclosed personal information to youth is related to an alleged disclosure that S1 shared personal information about themselves to C1 that may have been inappropriate or triggering to youth in care. When interviewed, C1 disclosed that S1 shared a traumatic event that had happened to themselves and that this information and/or disclosure was triggering to C1 due to their own trauma. During an interview with S1, they denied that they shared more than peripheral information about themselves in an effort to demonstrate to youth that it is possible to overcome their circumstances. S1 denied sharing any traumatic information about themselves as they understand that personal stories can be triggering to youth in care and can take the focus off of youth in care. As a result of the information obtained and interviews conducted, the allegation that staff disclosed personal information to youth is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. The allegation that staff spoke inappropriately to youth is related to a disclosure made by C1 that S1 spoke to C1 about a romantic text between S1 and S2. During confidential interviews, both staff denied any romantic interest and/or text messages between themselves. C1 refused interview with LPA Hill and would not elaborate on any information to assist in the investigation. As a result of the information obtained and interviews conducted, the allegation that staff spoke inappropriately to youth is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with Ms. Randle and documentation was provided, along with appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 4/17/24 at 1: PM and met with Haley Randle, Director of Youth Residential Programs to discuss the findings of this complaint investigation. LPA Hill informed Ms. Randle that the complaint investigation included an initial inspection to the facility on 2/8/24 and collateral inspections were conducted 2/8/24, 3/21/24, and 4/5/24 to interview staff and clients in care. During the collateral inspections, LPA Hill interviewed three staff and one client. The allegation that staff allowed a youth to smoke in staff's personal vehicle is related to a transport of C1 conducted by S1 (see LIC811 dated 4/17/24) on 1/29/24. The incident involved S1 taking the agency van back to the school location to retrieve S1's personal vehicle that was left behind due to staff being need that day for transport from the agency's nonpublic school to the facility. S1 states that this was out of the normal for them and that normally they arrived at the facility to begin their shift. C1 asked S1 to go along for the ride and upon receiving approval from the administrator, S1 took C1 with them. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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 SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: SUMMITVIEW CHILD & FAMILY SERVICES - SUGAR PINEFACILITY NUMBER: VISIT DATE: 04/17/2024

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


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Narrative:
in an effort to combat the pests, the facility staff and clients were also advised to wash all of the clothing, bedding, and maintain a clean the facility. While the facility did all of this, the bed bug issue persisted and the youth in the facility continued to complain about bed bug bites. Documentation shows that the facility became aware of the bed bug issues in the facility on 4/1/24 and began treatments including spraying the facility, washing youths' clothes, stripping of the beds and laundering of the clothing and bedding for the youth. Based on interviews with staff and clients, staff attempted to launder youths' clothing and bedding and this proved unsuccessful and the pests persisted. As of 4/12/24, the facility maintenance, in consultation with a local pest control, attempted to rid the facility of the pests by spraying the interior of the house with chemicals on a weekly basis as advised by the local pest control and advising all staff to pack up youths' belongings, including soft items, into bins once laundered but this did not resolve the issue. As of 5/6/24, documentation obtained from the facility indicates that the initial treatments were not successful and the agency hired a local pest control, Hangtown Pest Control, to conduct a more thorough treatment, including "three treatments over three weeks". This treatment required all clothing items to be washed and dried on hot settings and other items to be placed in large containers and stored until the treatment was complete. Beds were to be stripped daily and the rooms deep cleaned for the three weeks and all personal items could not be returned to the youths' bedrooms for the three weeks. The agency knew about the bed bug issue in the facility and attempted to address the issue in-house in April 2024 but they were not successful at combating this issue until hiring a professional pest control in May 2024 to render the services necessary, prolonging the treatment and presences of the pests in the facility. While the facility did not sit idle and ignore the pest issue, they did prolong treatment by attempting to address the pests in-house and not using a professional service as needed. As a result of this, the allegation that the facility did not address pests is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Ms. Randle and documentation was provided, including appeal rights.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 5/24/24 at 1: PM and met with Haley Randle, Director of Youth Residential Programs to discuss the findings of the allegations as stated. LPA Hill informed Ms. Randle that the investigation included an initial physical plant inspection on 4/5/24. A collateral inspection at the agency was also conducted on 4/5/24 where interviews with four youth and one staff were conducted. An additional collateral inspection was conducted on 4/17/24 where LPA Hill obtained documentation related to pest control and an interview with maintenance was conducted. LPA Hill received documentation related to the treatment of the pests, bed bugs, that indicated the facility maintenance had collaborated with the local pest control on the best treatment option and the facility implemented periodic pest management as indicated. While maintenance staff were spraying the facility UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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 SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: SUMMITVIEW CHILD & FAMILY SERVICES - SUGAR PINEFACILITY NUMBER: VISIT DATE: 05/24/2024

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


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Narrative:
This complaint investigation named S1 in addition to S2, S3, and S4 as providing vaping devices, including tobacco and marijuana, to youth in care. S1 was interviewed for the previous complaint investigation and S1 denied ever providing a vaping device to a youth in care. S1 made statements eluding to the agency not paying them enough to purchase vaping devices to give to youth in care. S1 did acknowledge that one youth (not connected to this investigation) saw their personal vaping device in their car during a transport one time and requested to "hit it" but S1 denied allowing youth to use the vape. S2, S3, and S4 were all interviewed and all staff denied supplying vaping devices to youth in care. S1 did not continue to work for the agency following the previous investigation due to reasons not solely related to the allegation. Law enforcement interviewed C1 and this is where additional staff were named (S2, S3, S4) and that disclosure indicated that they directly provided vapes, had direct knowledge about the vapes and who was supplying them, or were in collaboration with staff providing vapes to youth in care. C1 also disclosed that C4, and C2 and C3 (who do not live at this facility) all knew about the vapes and knew the staff named were providing vapes to youth in the agency. Following the complaint allegation, C1 did not return to the facility. When interviewed, S2, S3, and S4 all denied ever providing vaping devices to youth in care and denied knowing that youth were getting vaping devices from any staff working for the agency. Staff indicated that they thought youth were bringing in vapes when returning from home passes, from youth who attended public schools in the area, or when the youth residing in the facility interact with outside youth that come to the agency for therapy and groups in the afternoons. Staff stated that they thought the vapes were brought in by youth and subsequently passed to other youth in the agency and through the different facilities as this is what youth indicated when vaping devices were recovered. C2 and C3 were interviewed on 6/27/24 and neither could confirm that they paid staff or requested that staff provide vapes or that they saw a transaction of this nature. Both youth stated that they only heard rumors about this happening but had no direct proof or knowledge and no staff ever confirmed this directly to either youth. Both youth talked about S1 taking money from youth for snacks and bringing back snacks to youth but neither disclosed any information about S1 or any other staff providing vapes. C4 was interviewed in conjunction with the previous complaint investigation and they too denied knowing about, receiving, or seeing any staff provide vapes to youth in care. All youth confirmed that they heard about S1 providing vapes via rumors throughout the agency but none indicated that they had any proof. The allegation that staff threatened minors in care is related to the providing of the vapes and alleges that S1 threatened to get youth kicked out of the program if they told administrative staff or anyone about S1 providing the vaping devices. The interview conducted by law enforcement indicates that C1 denied being threatened by staff about the vaping devices but a subsequent interview of C1 conducted by C1's social worker indicated that C1 revealed they felt threatened and did not want to return to the agency as they felt that they would be retaliated upon or that C1 would be targeted as a snitch for making the report. No other youth confirmed any threats as they denied being involved with or receiving vaping devices. As a result of the interviews conducted and investigation completed the allegations that staff is providing smoke contraband to minors in care and that staff threatened minors in care are UNSUBSTANTIATED at this time meaning the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview was conducted with Ms. Gleason and documentation was provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 7/18/24 at 9: AM and met with Anna Gleason, Chief Executive Officer to discuss the findings of this complaint investigation. LPA Hill informed Ms. Gleason that the investigation included an initial inspection on 4/11/24 where documents related to staff and clients in care was obtained. This complaint investigation was referred to our Investigations Branch (IB) for further investigation where IB obtained police reports resulting from the cross report of these allegations. LPA Hill documented the Law Enforcement Interviews conducted with staff and youth interviewed. LPA Hill interviewed S1, S2, S3, S4, and youth C3 and C4 (see LIC811 dated 7/18/24) on 6/27/24. The allegation that staff is providing smoke contraband to minors in care was originally investigated via complaint dated 3/13/24 where only S1 was named as providing the smoke contraband to youth in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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 SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: SUMMITVIEW CHILD & FAMILY SERVICES - SUGAR PINEFACILITY NUMBER: VISIT DATE: 07/18/2024

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

met_with: Anna Gleason, Chief Executive Officer


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Narrative:
The allegation that staff were providing vaping devices to minors in care is related to an allegation that S1 and S2 were providing vaping devices, including tobacco and marijuana, to youth in care. Confidential interviews conducted by the Sheriff's Office alleged that S1 was providing vapes to youth in care without it being asked of S1 or the youth directly requesting them. It was also alleged that S1 never requested youth to pay for the vaping devices or that any money was exchanged for the purchase of the vaping devices. A vaping device was turned in to LPA Hill during an interview that youth alleged came from S1. This vaping device was given to Director of Youth Residential Programs by LPA Hill immediately following the interview. At the time of this disclosure, S1 had recently been discharged from their employment with the agency due to this being the second allegation involving vaping devices and other reasons, not related. A previous investigation and interview with C5 alleged that S1 allowed C5 to use S1's vaping device during a transport in S1's personal vehicle but S1 denied that this happened. S1 stated that the vaping device was in plain sight in their vehicle initially and that when C5 remarked about the vaping device, S1 removed the vaping device from sight and did not allow C5 to use it. This allegation was not substantiated. One youth originally alleged that S1 and S2 were providing vaping devices to youth in care but when interviewed by this LPA, that same youth denied any knowledge about staff providing vaping devices to youth. Youth stated that they heard one time a youth say something about obtaining a vaping device from staff but that they didn't believe the allegation and had no additional information about the allegation. When interviewed, S2 denied ever providing a vaping device to a youth in care. S2 went on to state that they do not smoke at work as they do not want youth to smell anything on them. S2 denies that they would ever provide a vaping device to youth in care. Interviews with additional staff indicated that youth tend to recirculate old allegations and rumors, sometimes allegations even prior to the youth arriving at the agency, including this same allegation related to staff providing vaping devices or allowing youth to take a hit off their personal vaping devices but there is no evidence or proof of this currently happening. The Chief Executive Officer (CEO) states these recirculated rumors only makes it harder for the agency decipher \what is happening now versus what is being drug up about old stuff. CEO states that all of this has prompted the agency to implement a policy whereby staff are prohibited from having vaping devices on their persons in the facility, not being allowed to have vaping devices left in plain sight in their vehicles, and their vehicles needing to be locked at all times while on the facility property to deter youth from attempting to obtain them from staff unknowingly. Other confidential interviews with staff and clients failed to corroborate that any staff are providing vaping devices to youth in care. As a result of the investigation and interviews conducted and based on the information obtained from the El Dorado County Sheriff's Office, there was not a preponderance of the evidence that staff providing vaping devices to youth in care despite the allegations made by youth. As a result, the allegation that staff are providing vaping devices to youth in care is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Ms. Gleason and documentation, along with appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Tamara Hill made an unannounced complaint inspection on 7/18/24 at 9: AM and met with Anna Gleason, Chief Executive Officer to discuss the findings of this complaint investigation. LPA Hill informed Ms. Gleason that the investigation included an initial inspection on 3/21/24 where documents related to staff and clients in care were obtained. LPA Hill interviewed C1 to C8 and S1 to S8 (see LIC811 dated 7/18/24) were interviewed from 3/21/24 through 6/27/24 by LPA Hill. LPA Hill haulted additional investigation in April 2024 due to another complaint allegation of a similar nature coming in and being referred to the Department's Investigaitons Branch (IB). IB was able to obtain El Dorado County Sheriff Office's (Sheriff) interviews with the named staff persons and other documentation and this information provided a basis for the findings of this complaint investigaiton. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Tamara Jensen-Hill 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 SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: SUMMITVIEW CHILD & FAMILY SERVICES - SUGAR PINEFACILITY NUMBER: VISIT DATE: 07/18/2024

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


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an announced inspection on 7/28/21 at 9: AM and met with Anna Gleason, CEO to tour the facility. The inspection on this date is for the purposes of relocation of one of the other facilities by the same licensee to this location. As such, all of the furnishings or other items were not present in the facility as would be expected for new licenses. LPA did observe some non perishable food items, chemicals used for cleaning and other furniture items in the facility. During the inspection today, the following items were noted: Kitchen had some of the required dishes, appliances and silverware for client use. LPA also observed that the kitchen has a locked storage cabinet where medications are to be stored. The kitchen had a covered trash can. There is an island with plenty of additional storage space for storage of other cooking supplies as needed. LPA did observe a missing drawer handle and was informed that maintenance is out attempting to obtain longer screws to fix this drawer. LPA observed a refrigerator and stove for cooking in the kitchen. LPA observed a fire extinguisher near the kitchen area with an inspection tag dated 7/7/21. LPA observed a closet near the front door of the facility that has a lock for storage of the cleaning supplies for this house. LPA observed that there are three dual occupancy client bedrooms in the facility that were all well stocked with dresser space, beds and night stands as required. There are no lamps but LPA did observe that each of these rooms had central lighting in the rooms. LPA observed that the screens for the windows and slider in the client rooms were present. LPA did not observe any missing screens on any of the windows. LPA observed two client bathrooms: the front bathroom was equipped with two sinks, toilet and tub and shower combination. LPA observed that there is hot water in the sinks and shower. There is an abundance of storage space in this bathroom. LPA did advise that the shelves in the vanity be removed/replaced as they are glass. Back bathroom was equipped with a shower, toilet and sink for client use. LPA observed that this bathroom also has adequate storage space. Back patio was observed to have two exits and the south exit was observed to have a broken stair. LPA was informed that the side with the broken step will be permanently blocked and stairs removed. Currently, that side of the patio is temporarily blocked by wood. LPA observed that the laundry facilities are off the kitchen as well as additional storage space for cleaning supplies and other toiletries such as toilet paper and paper towels. LPA observed that this room also housed the wifi equipment and DVR (cameras) system. LPA observed that the property has a locked well house (as the property functions off well water), a locked storage shed is located outside the converted garage area (not converted by the agency rather converted prior to purchase by sellers), LPA observed an additional dwelling located on the other side of the storage shed. The agency has not decided if that dwelling will be strictly storage or what the purpose of this building will be. Agency shall notify Licensing upon reaching a decision but shall maintain this dwelling locked and inaccessible by clients at all times. The main entrance for visitors, staff and clients will be the converted garage area and not the front entrance of the house as the entrance into the converted garage is closer to parking. This area shall also serve as storage for the facility and activities as necessary for the clients in care. LPA discussed the cameras observed throughout the facility and LPA did observe that the cameras are in the common areas only and on the exterior of the facility. The use of cameras shall not violate the personal rights of youth in care as they shall not capture audio and are not used in client bedrooms or bathrooms. LPA verified via email with fire inspector on 7/28/21 that the facility does have a fire clearance per their inspection. Inspector neglected to fax over the STD 850 to verify but agreed to do that first thing 7/29/21. LPA observed that the facility appears ready to receive clients and is recommending that the facility be licensed as of 7/28/21. Exit interview was conducted with Anna Gleason, CEO and document was provided via email.

visit_type: Prelicensing


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection on 11/12/21 at Placerville Drive, Placerville at 1: PM and met with Monika Gleason, Youth Residential Program Administrator and Anna Gleason, Chief Executive Officer to discuss an incident report. LPA informed Ms. Gleason that the incident involves two youth from this location, C1 and C2 (see LIC811 dated 11/12/21) where one client is alleging that an other client is being sexually inappropriate with them. LPA was able to interview C1 while at the agency during this visit. LPA could not speak with C2 as they were not present at the agency. LPA informed Ms. Gleason that additional investigation on this case management is needed and an additional visit will be necessary another day. LPA discussed with Anna Gleason another incident report including one from 9/23/21 where C3 refused to comply with medications and curfew and subsequently left the facility on an unauthorized absence following a statement about suicidal ideation. The report indicates that staff was not able to follow due to being the only staff in the facility at the time. LPA discussed the report with Anna Gleason in that it appears that C3 was struggling and had been struggling from the time that they were supposed to be sleeping until well after 12: AM and there was not an additional staff present to assist staff with client. LPA learned that behavior was common for this youth and was not alarming to staff until C3 left on the unauthorized absence. Anna Gleason states that the staff did respond quickly and C3 was returned to the facility but not articulated in the incident report. LPA reminded the agency that they need to have a full picture of the incident report and this should include the antecedent or what was happening prior to the incident, what happened during the incident as well as what happened after the incident. Anna Gleason states that she will send out a reminder to all staff of this. No citations were issued and exit interview was conducted. Document was provided to the agency.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced post licensing inspection at the facility on 3/25/22 at 11: AM and met with Anna Gleason, Chief Executive Officer . LPA toured the facility inside and out and found that the physical plant of the facility was in substantial compliance during the inspection. LPA observed that the house was equipped with three dual occupancy client bedrooms and two bathrooms accessible to clients in care. All bedrooms were fully equipped with appropriate bedding and furnishings as required. The bathrooms were properly equipped with appropriate supplies and LPA did not find anything in that bathrooms that should not otherwise be accessible to clients. LPA observed that the smoke detectors were functioning as required and that there is a carbon monoxide detector in the home. LPA did advise that the carbon monoxide detector be moved to be closer to client bedrooms rather than be in the living room of the facility. LPA observed that there was adequate food, perishable and nonperishable, in the facility for the clients in care. LPA observed that the facility looked clean and tidy during the inspection. All clients were at their school program during the inspection. LPA observed that the exterior of the home is well taken care of and that there is adequate room for clients to do activities outside. LPA advised that the couple of branches observed in the yard be removed so as to not present a trip hazard to clients. LPA also advised that the additional building needs to have access during the annual inspection that will be happening in July or prior to. LPA looked inside of the additional buildings on the property through the windows and it is obvious that nobody is living in the building and it is empty. LPA also looked inside the shed in the driveway and LPA observed that there are a couple of ladders in there and that there was nothing else of substance. LPA returned to the administrative buildings to review staff and client files on this date but there was not enough time to complete all of the review. LPA informed the agency that an additional visit will need to be conducted to interview client and staff and to review documents. LPA obtained client copies of files during the visit and will complete documentation related to client and staff files at a later visit. LPA will review staff files at a later visit with the agency as well. LPA did not observed any violations during the visit and an exit interview was conducted with Anna Gleason, Agency Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tamara Hill made an unannounced case management inspection at the facility administrative office on 3/25/22 at 12: PM and met with Anna Gleason, Chief Executive Officer. The purpose of the inspection on 3/25/22 was to discuss the following incident reports related to the facility: 2/20/22 - C1 experienced an episode in the bathroom lasting 2.5 hours and staff informed C1 that they were calling emergency services for an evaluation and youth acknowledged that it might be best for them. The report does not indicate that they were called. LPA informed Ms. Gleason that there is a lot missing from this report and not a clear picture of what happened or why they did not call emergency services or if they did. LPA asked that the agency rewrite the report with a clear picture of what transpired and resubmit it to LPA. 12/9/21 - C1 was restrained for trying to go AWOL. Youth was pulled back into the facility through an open window. LPA explained to the agency that restraints are not allowed strictly for attempts to AWOL. LPA provided that the agency needs to constantly evaluate situations such as these as the youth have a right to leave the facility as part of their Personal Rights. 12/1/21 - C2 was on a "Safety Watch" as indicated in the incident report but there is no information as to why. LPA explained that a youth being on a safety watch does not automatically mean that they do room searches or any other action that violates a youth's personal rights. LPA did not issue citations on this date but did discuss additional training needs for staff regarding room searches, restraining of youth, safety watches, and incident report writing. LPA did provide that when physical intervening a youth that is attempting to leave the facility, this requires additional documentation to accompany the incident report. LPA is aware that the agency is undergoing some major changes that would include a change in facility type and understands the struggles regarding staffing. Exit interview was conducted and document was provided to Ms. Gleason.