summary: Facility Evaluation

raw_content:
Narrative:
On March 28, 2023, at 9: AM, Licensing Program Analyst (LPA) Charmetha White made an unannounced visit to Sycamores STRTP South Campus, for the purpose of conducting a Post Licensing Inspection. LPA met with the Vice President of Sycamores, Gina Peck-Sobolewski, who granted access to the facility and together a tour of the entire interior and exterior physical plant was conducted. The facility is a Short Term Therapeutic Residential program that provides care and supervision for up to sixteen (16) male youth ages 11 - 17 years old, and non-minor dependents, ambulatory only. The census at the time of this inspection was 9. The Facility is located in a residential neighborhood and is composed of three (3) cottages: Swartzott, Hutter, and Baldwin. Each cottage is set up as follows: Swartzott Cottage houses 8 clients and it is composed of the following: Living room, Kitchen, four (4) bedrooms, and two (2) bathrooms. The cottage census at the time of this inspection was four (4). Living room: is equipped with couches, a coffee table, a mounted enclosed television cabinet, a TV, and a regulation fire extinguisher. Kitchen: is equipped with refrigerator/freezer, a four (4) burner gas stove, a dishwasher, a microwave, a regulation fire extinguisher, and a trash can with a lid. LPA observed the cottage to use paper plates, cups, and plastic utensils. Food is prepared in the main dining area of the facility and brought over to the cottage. Bedrooms: each bedroom is equipped with two (2) twin beds, two (2) cabinets, working lights, and windows. LPA observed each bed to have clean linens and pillows. Bathrooms: one (1) bathroom is located at the end of the hallway near bedroom #1, and one (1) bathroom is located inside of bedroom #3. Each bathroom is equipped with a toilet, sink, and a shower all in working order. The water temperature was tested and found to be between 105 -120 degrees F. Hutter Cottage houses 8 clients and it is composed of the following: Living room, Kitchen, Laundry room, four (4) bedrooms, and two (2) bathrooms. The cottage census at the time of this inspection was five (5). Report continued on LIC 809C (Page 1 of 3). Living room: is equipped with couches, a coffee table, a mounted enclosed television cabinet, a TV, and a regulation fire extinguisher. Kitchen: is equipped with refrigerator/freezer, a five (5) burner gas stove, a dishwasher, a microwave, a regulation fire extinguisher, and a trash can with a lid. LPA observed the cottage to use paper plates, cups, and plastic utensils. Food is prepared in the main dining area of the facility and brought over to the cottage. Laundry room: is located adjacent to bedroom #4 and accessible from the outside. It is equipped with a washer and dryer. Bedrooms: each bedroom is equipped with two (2) twin beds, two (2) cabinets, working lights, and windows.LPA observed bed to have clean linens and pillows. Bathrooms: are side by side and are located along the hallway. Each bathroom is equipped with a toilet, sink, and a shower all in working order. The water temperature was tested and found to be between 105 -120 degrees F. Baldwin Cottage is used as the facility's isolation area and satisfies ILS regulation 87075(e): it is composed of a Dining room, Living room, Kitchen, Conference room/Staff office, Laundry room, four (4) bedrooms, three (3) bathrooms, and a Storage room. There were zero (0) clients in isolation at the time of this inspection. Dining room: is equipped with a table and chairs. Living room: is equipped with couches, a coffee table, a mounted enclosed television cabinet, a TV, video game console, and a regulation fire extinguisher. Kitchen: is equipped with refrigerator/freezer, a four (4) burner gas stove, a dishwasher, a microwave, a regulation fire extinguisher, and a trash can with a lid. Conference room/ Staff office: is located next to the laundry room and accessible from outside. The room is equipped with a table and multiple chairs. Laundry room: is located outside next to the conference room/staff office and it is equipped with a washer and dryer. Storage room: LPA observe this room to be empty. Bedrooms: each bedroom is equipped with two (2) twin beds, two (2) cabinets with built in lockers, working lights, and windows. Bathrooms: one (1) bathroom is located inside bedroom #2 and it is equipped with a toilet and sink; one (1) bathroom is located in the hallway next to bedroom #3 and it is equipped with a toilet, sink, and shower; one (1) bathroom is located next to the dining room, and it is equipped with a toilet, sink, and shower. All bathrooms were observed to be in working order. The water temperature was tested and found to be between 105 -120 degrees F. Report continued on LIC 809C (Page 2 of 3). Smoke alarms and carbon monoxide detectors were tested and found to be in working order. First Aid kits checked and found to be complete. LPA observed the cottages to have cameras in the common areas and on the outside perimeter of the buildings. The cameras are monitored by the administrative staff and the IT Department. There is a camera waiver on file. Disinfectants/cleaning solutions are stored in the maintenance room and made inaccessible to clients. All medication is centrally stored in the nurse's office and the facility has an on-site nurse that provides medical care and to administer medication. Medication logs for clients are stored in the nurse office and available for review and audit as needed. Overall LPA observed the facility to be clean, safe, sanitary and in good repair. Clients have access to the following outdoor space: an outdoor garden next to Hutter Cottage, basketball court, recreational hall, swing set, and exercise equipment. The facility operates within license conditions and limitations including capacity limitations. The facility has an Emergency Disaster Plan in place. LPA discussed and advised the Licensee to ensure the following: Children are supported and encouraged to participate in extracurricular activities. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. Emergency Plan, Personal Rights, and menus were posted in each of the cottages. Transportation: The facility has a total of 7 vehicles to transport clients. LPA inspected 3 out of 7 vehicles and found seat belts and horn in working order, travel first aid kits, and current registration and insurance. Vehicles are insured by Nonprofit Insurance Alliance of CA and expire 11/1/2023. There are no deficiencies observed or cited at this during this inspection. An exit interview was conducted with the Vice President, and this report was left at the facility. (Page 3 of 3).

met_with: Vice President of Sycamores - Gina Peck-Sobolewski


state: CA

facility_name: HATHAWAY-SYCAMORES CHILD AND FAMILY SERVICES

summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On September 28, 2023, Licensing Program Analyst (LPA) C. White made an unannounced visit to Sycamores STRTP South Campus, for the purpose of conducting an Annual/Required Inspection. LPA met with the Administrator, Daisy Delgado, who granted access to the facility and together a tour of the entire interior and exterior physical plant was conducted. The facility is a Short Term Therapeutic Residential program that provides care and supervision for up to sixteen (16) male youth ages 11 - 17 years old, and non-minor dependents, ambulatory only. The census at the time of this inspection was zero (0). The Facility is located in a residential neighborhood and is composed of three (2) cottages: Swartzott and Hutter. Each cottage is set up as follows: Swartzott Cottage houses 8 clients; it is composed of the following: Living room, Kitchen, four (4) bedrooms, and two (2) bathrooms. The cottage census at the time of this inspection was zero (0). Living room: is equipped with couches, a coffee table, a mounted enclosed television cabinet, a TV, and a regulation fire extinguisher. Kitchen: is equipped with refrigerator/freezer, a four (4) burner gas stove/oven (all burners were operational at the time of this inspection), a dishwasher, a microwave, a regulation fire extinguisher, and a trash can with a lid. LPA observed there were no dishes or utensils in the cottage at the time of the inspection. All food is prepared and served in the main dining area located on the facility's premises. Bedrooms: each bedroom is equipped with two (2) twin beds, two (2) cabinets, working lights, and windows. LPA observed there were no pillows, or linens in any of the bedrooms. Bathrooms: one (1) bathroom is located at the end of the hallway near bedroom #1, and one (1) bathroom is located inside of bedroom #3. Each bathroom is equipped with a toilet, sink, and a shower all in working order. The water temperature was tested and found to be between 105 -120 degrees F. Hutter Cottage houses 8 clients; it is composed of the following: Living room, Kitchen, Laundry room, four (4) bedrooms, and two (2) bathrooms. The cottage census at the time of this inspection was zero (0). Report continued on LIC 809C (Page 1 of 3). Living room: is being used for storage. LPA observed several large wooden cabinets with built in lockers, a mounted television enclosure, a metal storage shelve with boxes, and a few wooden desk stored in this area. Kitchen: is equipped with refrigerator/freezer, a five (5) burner gas stove/oven (all burners were operational at the time of this inspection), a dishwasher, a microwave, a regulation fire extinguisher, and a trash can with a lid. LPA observed there were no dishes or utensils in the cottage at the time of the inspection. All food is prepared and served in the main dining area located on the facility's premises. Laundry room: is located adjacent to bedroom #4 and accessible from the outside. It is equipped with a washer and dryer. Bedroom #1: is being used for storage. LPA observed several large wooden cabinets, several mattresses, and a chair stored in this room. Bedroom #2 & #3: is equipped with two (2) twin beds, two (2) cabinets, working lights, and windows. LPA observed there were no pillows, or linens in any of the bedrooms. Bedroom #4: is being used for storage. LPA observed several wooden desks, a large wooden cabinet, two small round tables, a few plastic storage bins, extra fans, and a vacuum stored in this room. Bathrooms: are side by side and are located along the hallway. Each bathroom is equipped with a toilet, sink, and a shower all in working order. The water temperature was tested and found to be between 105 -120 degrees F. Smoke alarms and carbon monoxide detectors were tested and found to be in working order. First Aid kit is located in the nurse's office. LPA observed the cottages to have cameras in the common areas and on the outside perimeter of the buildings. The cameras are monitored by the administrative staff and the IT Department. There is a camera waiver on file. LPA did not observed any disinfectants/cleaning solutions stored in either of the cottages. All medication is centrally stored in the nurse's office and the facility has on-site nurses that provide medical care and administer medication. Medication logs for clients are stored in the nurse office and available for review and audit as needed. The outdoor space consists of the following: a garden next to Hutter Cottage, a basketball court, a recreational hall, a swing set, and exercise equipment. The facility has an Emergency Disaster Plan in place. LPA reminded Licensee to ensure the following when children are in placement: Children are supported and encouraged to participate in extracurricular activities. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the facility. LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. Emergency Plan, Personal Rights, and menus were posted in each of the cottages. Report continued on LIC 809C (Page 2 of 3). Transportation: The facility has a total of 7 vehicles to transport clients. LPA inspected 3 out of 9 vehicles and found seat belts and horn in working order, travel first aid kits, and current registration and insurance. Vehicles are insured by Nonprofit Insurance Alliance of CA and expire 11/1/2023. Administrator Daisy Delgago is present at the facility with a minimum of 20 hours a week, as verified by staff schedule. Licensee is in the process of obtaining Mental Health Certification, the application and Mental Health Plan was submitted to DHCS on 4/19/23. Licensee has obtained National Accreditation through The Joint Commission. The Accreditation is valid through July 17th, 2024. The facility has a camera waiver that is meeting the terms and conditions that approved when the facility was a licensed group home. There were deficiencies cited per California Code of Regulations and Interim Licensing Standards. Exit interview was conducted, Appeal Rights and a copy of this report was given to the Administrator. (Page 3 of 3)

Deficiencies:
87088: (1) An individual bed maintained in good repair; equipped with good springs and a clean mattress; and supplied with pillow(s) which are clean and in good repair.

report_type: Facility Evaluation

visit_type: Annual

met_with: Administrator - Daisy Delgado

title: Fixtures, Furniture, Equipment, and Supplies (c)The licensee shall provide and make readily available to each child the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene


summary: Facility Evaluation

raw_content:
Narrative:
On October 27, 2023, Licensing Program Analyst (LPA) C. White arrived at Sycamores STRTP South Campus, for the purpose of conducting a Plan of Correction (POC) inspection in order to clear the deficiencies cited during the Annual/Required visit, conducted on 09/28/2023. LPA met with Administrator, Daisy Delgado who granted access to the facility. The deficiencies previously cited were: Type B - There were no pillows in any of the bedrooms. Section. 87088(c)(1). Type B - There were no linen in any of the rooms. There were no bath towels, hand towels, or wash cloths in any of the cottages. Section 87088(c)(2). Type B - There were no personal hygiene products in either of the cottages. Section. 87088(c)(3). Type B - The Living room, Bedroom #1, and Bedroom #4 in Hutter's cottage is being used for storage. Section. 87087.3(a). During this inspection, LPA was provided a tour of Swartzott Cottage and Hutter Cottage. LPA observed all bedrooms in each cottage to have pillows and new linen. Each cottage was equipped with a supply of personal hygiene products, bath towels, wash clothes, and hand towels. Additionally, all storage items had been removed from the living room, Bedroom #1 and Bedroom #4 in Hutter's Cottage. All deficiencies were cleared at the time of this inspection. LPA printed out the Deficiency Clearance Letter and provided it to the Administrator. There are no deficiencies cited California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS). Exit interview was conducted and a copy of this report was left with the Administrator.

met_with: Daisy Delgado - Administrator


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Additionally, confidential interviews stated that FC2 was angry at FC1 and hit FC1. Other Confidential interviews confirmed that FC1 and FC2 were horseplaying prior to the incident and FC1 and FC2 were prompted to stop. Additional interviews reported that there were no other witnesses to this alleged incident. LPA received inconsistent information regarding the allegation. Based on confidential interviews, the allegation that FC1 sustained a fracture while in care due to a lack of supervision may have occurred, however, it is not supported or proven by evidence. Therefore, the above allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Facility Administrator Trina Sanford.

Investigation Findings:
13On November 24, 2021 at 3:00PM, Licensing Program Analyst (LPA) Adaleyci Caballero met with S.A.M.'s Facility Administrator Trina Sanford to discuss the investigative finding for the above stated allegation for foster child #1. LPA Carol Anderson began the investigation at the facility on April 9, 2021 at 2:00PM. LPA Adaleyci Caballero conducted a collateral visit to interview Foster Child #1, #2, #3, #4, and Staff #1. Facility Administrator Trina Sanford was interviewed via telephone. LPA reviewed previous incident reports. Community Care Licensing received information on April 7, 2021 alleging that foster child #1 (FC1) sustained a fracture while in care. It was specified that foster child #2 (FC2) hit FC1 on the nose causing it to bleed and possibly dislocated/broken it. Confidential interviews stated that both FC1 and FC2 were horseplaying and it was caused on accident. Confidential interviews stated that FC1 nose was not dislocated or broken. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Adaleyci Caballero 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: S.A.M.'SFACILITY NUMBER: VISIT DATE: 11/29/2021

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

report_type: Complaint Investigation

met_with: Trina Sanford

complaint_status: unsubstantiated


facility_name: REFUGE, THE

raw_content:
Narrative:
All interviewees denied Y2 or another youth in care has received a concussion. Staff reported that when the verbal altercation started between Y1 and Y2, staff utilized various de-escalation techniques. Staff reported the incident occurred very quickly. According to staff interviews, as Y1 was leaving the area, Y1 picked up the drying rack and threw the drying rack at Y2. Staff reported that S1 was able to deflect the drying rack however the object hit Y2. All staff interviews denied any of the youth in care received a concussion. One CSW reported they had no concerns regarding the physical altercation while another CSW reported they were unaware of the physical altercation. LPA's record review documented this was the only physical altercation at the facility. Based on confidential interviews the allegation that staff (S1, S2) failed to protect youth (Y2) from being harmed by other resident (Y1) may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, a copy of this report and appeal rights were emailed to Administrator Amaneece Harrison. A copy of the signed report will be placed in the facility file.

Investigation Findings:
13On June 16, 2021 at 04:00pm Licensing Program Analyst (LPA) Kendal Zirbes met with Administrator Amaneece Harrison to deliver the investigative finding for the above stated allegation. During the investigation, LPA interviewed three of three youth, two County Social Workers (CSW), one Facility Manger, the Administrator, Therapist, and two Direct Care staff members. Furthermore, LPA completed a review of the facility records. LPA Zirbes completed a virtual safety inspection of the STRTP on March 9, 2021 at 10:15am, there were no deficiencies noted. On March 1, 2021, the Department received an allegation that on an unknown date, youth 1 (Y1) gave two unknown youth concussions. Confidential interviews reported there was one physical altercation that occurred at the facility. According to the confidential interviews, youth 2 (Y2), youth 3 (Y3), Y1, staff 1 (S1) and staff 2 (S2) were present during the altercation. Confidential interviews reported Y1 threw a drying rack at Y2, which hit Y2 on the side of the head. Confidential interviews reported the staff utilized de-escalation techniques and could not have prevented the altercation. Other confidential interviews reported that if the staff had intervened sooner, Y1 may have been prevented from throwing the drying rack. Report continued on page two UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Christina Barnes LICENSING EVALUATOR NAME: Kendal Zirbes 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 08-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, METROPOLITAN DR. # FACILITY NAME: REFUGE, THEFACILITY NUMBER: VISIT DATE: 06/16/2021

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

met_with: Administrator, Amaneece Harrison


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
Staff reported CSW could not provide transportation therefore, Y1's appointment was missed. CSW reported the facility did not tell the County about the appointment until the day of the appointment, April 20, 2021. CSW further stated that during the Child and Family Team Meeting on April 19, 2021, the facility did not mention Y1's appointment. CSW reported that if the facility had provided the County with more time, transportation could have been arranged. LPAs review of the program statement found the facility was following the transportation policy. However, the facility failed to inform the CSW about the appointment in a timely manner therefore Y1 did not have access to the medical appointment. Based on confidential interviews, there is a preponderance of evidence to prove staff (names unknown) did not provide resident (Y1) access to medical services. The facility is cited under the Interim Licensing Standards, Version 3, regulation 87072 (17) Personal Rights. An exit interview was conducted, a copy of this report and appeal rights were provided to the facility manager.

Investigation Findings:
13On June 29, 2021, Licensing Program Analyst (LPA) Kendal Zirbes met with Facility Manager Grace Williams to deliver the investigative finding for the above stated allegation. During the investigation, LPA interviewed two youth, the Administrator, a facility manager, three direct staff care staff members, and one County Social Worker (CSW). In addition, LPA completed a review of the facility records. On May 13, 2021 a safety inspection was conducted by LPA Zirbes, no deficiencies were observed. On May 7, 2021, the Department received information that unknown staff members, failed to provide youth 1 (Y1) with access to a medical appointment. Confidential interviews reported Y1 had a medical appointment scheduled for April 20, 2021. Confidential interviews reported the appointment was missed due to a lack of transportation. Additional confidential interviews reported there were no problems with transportation to medical appointments. Staff reported that on April 10, 2021, Y1 made an appointment without the consent of the facility. Staff further reported that Y1 was informed, that the facility could not provide transportation to the appointment as indicated by the program statement. Staff members reported that on April 19, 2021, Y1's CSW was informed that transportation was needed for the appointment on April 20, 2021. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Christina Barnes LICENSING EVALUATOR NAME: Kendal Zirbes 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 08-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, METROPOLITAN DR. # FACILITY NAME: REFUGE, THEFACILITY NUMBER: VISIT DATE: 06/29/2021

met_with: Facility Manager, Grace Williams

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Based on record review, there is a preponderance of evidence to prove the facility is not operating within their plan of operation. The facility is cited under the Interim Licensing Standards, Version 3, regulation 87022 (f) Plan of Operation. On June 7, 2021, the facility was cited under 87022 (f) Plan of Operation therefore, civil penalties will be assessed. An exit interview was conducted, a copy of this report and appeal rights were provided to the facility manager.

Investigation Findings:
13On June 29, 2021, Licensing Program Analyst (LPA) Kendal Zirbes met with Facility Manager Rachel Beck to deliver the investigative finding for the above stated allegation. During the investigation, LPA interviewed the one direct care staff, one facility manager and the administrator. In addition, LPA completed a review of the facility records. On June 16, 2021 at 04:15pm a safety inspection was conducted by LPA Zirbes, no deficiencies were observed. On June 10, 2021 the Department received information that on May 28, 2021 the facility conducted an intake interview with Youth 1 (Y1). On June 8, 2021, the authorized representative was notified that Y1 would not be accepted into the program. LPA review the facilities approved Plan of Operation which stated: "After the intake interview, our agency will communicate acceptance or rejection of the referral within five business days...". Information received from staff members confirmed the facility failed communicate acceptance or rejection within time allotted by the program statement. Therefore, the facility notified the authorized representative seven days after the intake interview instead of five days as required in the approved in the program statement. Report continued on page two SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Christina Barnes LICENSING EVALUATOR NAME: Kendal Zirbes 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 08-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, METROPOLITAN DR. # FACILITY NAME: REFUGE, THEFACILITY NUMBER: VISIT DATE: 06/29/2021

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


raw_content:
Narrative:
***This is an amended document*** interviews and record review revealed S1 corroborated the purchases were intended for C1 and provided to C1. An additional allegation alleging Staff (S1) made inappropriate comments to minor (C1) in care was also received by CCL. Specifically, it was reported S1 made inappropriate sexual comments to C1 on at least two occasions. Confidential interviews provided consistent statements of S1 making sexual comments to C1 about C1 and other staff working at the facility. Based on confidential interviews and record review the allegations Staff (S1) purchased a vape pen for minor (C1) in care, Staff (S1) made inappropriate comments to minor (C1) in care, and Staff (S1) purchased alcohol for minor (C1) in care are substantiated. The preponderance of evidence standard has been met. Facility is cited for two violations Health and Safety Code 1550(c) Conduct Inimical: Conduct which is inimical to the health, morals, welfare or safety of either an individual in or receiving services from the facility or people of this state. A copy of the amended report and appeal rights was discussed and provided to Michele Hazelwood, House Manager of The Refuge

Investigation Findings:
13This is an amended report originally delivered on August 8, 2022. On August 8, 2022 at 2:07 pm Licensing Program Analyst (LPA), Nicole Strickland, met with Grace Williams, Executive Director of The Refuge to deliver the finding for the above stated allegations. The investigation was conducted by Special Investigator (SI) Rey Lyyjoki and LPA Strickland and included interviews with one of one foster youth, three staff members (Staff #1 [S1], Staff #2 [S2], and Staff #3 [S3]), San Marcos Sherriff's Detective and Executive Director (ExDir). In addition, county records and facility records were reviewed. On March 23, 2022, Community Care Licensing (CCL) received two allegations alleging Staff (Staff #1 [S1]) purchased a vape pen for minor (Child #1 [C1]) in care and S1 purchased alcohol for minor (C1) in care. Specifically, it was reported on March 4, 2022, S1 took C1 to the store where S1 purchased alcohol and a vape pen for C1. Confidential interviews, record review, and observation of photographs taken of the video surveillance from the store provided consistent accounts of S1 making the purchases. Confidential SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Nicole Strickland 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: REFUGE, THEFACILITY NUMBER: VISIT DATE: 08/08/2022

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

met_with: Grace Williams


raw_content:
Narrative:
evidence. Confidential interviews denied allegations of a lack of supervision as well as staff not preventing child from self-harm. According to confidential interviews, Child # 1 (C1) and Child # 2 (C2) got into a verbal argument in which staff immediately intervened to de-escalate the situation and separated the clients, one in each bedroom. According to confidential interviews, despite staff intervention, C2 pushed thru staff and barged into C1's bedroom hitting C1 in the head with a closed fist. According to confidential interviews, staff stood in between C2 and C1, receiving the brunt of C2's blows. According to confidential information, there was proper supervision and adequate staff during all stages of this incident. Confidential interviews also denied that staff failed to prevent C1 from self-harming. According to confidential interviews, C1 became upset after hearing disappointing news and locked themselves in the bathroom while making suicidal threats. According to confidential information, staff was counseling C1 during the incident and subsequently contacted authorities to have C1 evaluated. According to confidential information, C1 had not engaged in self-harm during this incident, and only made verbal threats of self-harm. While other confidential information received by Licensing Office stated that these allegations of a lack of supervision and self-harm had occurred, and that there was an inadequate response by staff during these incidents. Based on confidential information obtained during the course of this investigation, the allegations a lack of supervision resulting in Child # 2 (C2) causing harm to Child # 1 (C1) , as well as staff not preventing C1 from causing self-harm while in care, may have occurred, however is not supported or proven by evidence. Therefore, the above allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided.

Investigation Findings:
13Licensing Program Analyst (LPA), Daniel Mena met with House Managers, Marcus Strong and Michele Hazelwood to issue the investigative findings for the above stated allegations. Licensing Program Analyst (LPA), Lorena Valenzuela conducted an inspection to the Short Term Residential Therapeutic Program (STRTP) on August 30, 2021 at 10:50am. No immediate hazards observed. LPAs Valenzuela and Mena interviewed Administrator (AD), six staff (S1, S2, S3, S4, S5 & S6), Current Social Worker (CSW), one of three foster children (C2), as well as reviewed client and facility records. LPA was unable to interview Children # 1 (C1) and # 3 (C3) due to them currently being on AWOL status and LPA not being able to obtain current contact information from social worker. Community Care Licensing received information on August 26, 2021 alleging a lack of supervision resulting in Child # 2 (C2) causing harm to Child # 1 (C1) , as well as staff not preventing C1 from causing self-harm while in care. Information obtained in confidential interviews did not corroborate the allegations with a preponderance of UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Daniel Mena 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: REFUGE, THEFACILITY NUMBER: VISIT DATE: 08/18/2022

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

met_with: Michele Hazelwood


raw_content:
Narrative:
Confidential interviews also denied that any staff had ever physically or verbally harassed C1 while in care. According to confidential interviews, injuries observed on C1's arms were self-inflicted scratches or cuts that C1 had done to themselves while using a shaving razor inside the bathroom. While other confidential information received by Licensing Office stated that these allegations. LPA Mena spoke to C1's County Social Worker who stated that at this time they had no concerns regarding these allegations. Based on confidential information obtained during the course of this investigation, the allegations that facility staff was harassing and had sexually abused Child # 1 (C1), and that C1 has also sustained unexplained injuries while in care, may have occurred, however is not supported or proven by evidence. Therefore, the above allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided C1 while in care.

Investigation Findings:
13Licensing Program Analyst (LPA), Daniel Mena met with Staff Member, Destinee Jaime to discuss the investigative findings for the above stated allegations. LPA Daniel Mena conducted an inspection to the facility on August 18, 2022, at 11:21am. No immediate hazards observed. Special Investigator (SI), Ernestina Belluco and LPA Mena interviewed four Staff (S1, S2, S3 & S4), one of one foster children (C1), County Social Worker (CSW), County Investigator (COI), as well as reviewed client and facility records. Community Care Licensing received information on August 08, 2022, alleging that facility staff was harassing and had sexually abused Child # 1 (C1), and that C1 had also sustained unexplained injuries while in care. Information obtained in confidential interviews did not corroborate the allegations with a preponderance of evidence. IB investigator and LPA Mena obtained conflicting information during interviews. Confidential interviews denied allegations that Staff # 1 (S1) or any other staff had sexually abused C1 while in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Daniel Mena 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: REFUGE, THEFACILITY NUMBER: VISIT DATE: 03/03/2023

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

met_with: Destinee Jaime


raw_content:
Narrative:
The preponderance of evidence standard has been met, therefore the allegation S1 interacted inappropriately with C1 is found to be Substantiated. This posed an immediate Health, Safety or Personal Rights risk to the children in care. The facility is being issued a citation for violations of the Interim Licensing Standards, Chapter 7, Version 4, Sections 87078 (b) Responsibility for Providing Care and Supervision. See attached LIC 9099D for cited deficiency. An exit interview was conducted, appeal rights explained and a copy of this report was provided to Wanni Mena, along with the LIC 811.

Investigation Findings:
13On April 18, 2023, at 10:46 am, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced inspection to the facility to deliver the findings of the above allegation. LPA met with Wanni Mena . LPA Nicole Strickland conducted an inspection of the facility on September 06, 2022 at 04:18 pm and no immediate deficiencies were observed. Three of three clients (C1, C2, C3), three staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that on August 30, 2022, C1 was suicidal and wrapped a belt around the neck in attempts to commit suicide. Confidential staff interviews reported that staff #1 (S1) was able to get the belt off of C1's neck. Confidential staff interviews reported that staff did not seek any medical attention for C1 after the incident until the following day. All of the persons interviewed including C1 corroborated this information. Based on record review and interviews staff did not seek medical attention for C1 on August 30, 2022, after a suicidal attempt, and therefore C1's mental health needs were not met in a timely manner. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: REFUGE, THEFACILITY NUMBER: 374603969

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

met_with: Wanni Mena


raw_content:
Narrative:
The interviews that were provided to the LPA were not consistent regarding the allegations that staff are not properly supervising C1 and did not provide any further specific details regarding staff supervision. Based on interviews and record reviews the allegations that staff kicked and yelled at C1 and S1 used inappropriate language towards C1, may have occurred, however is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Destinee Gastelum.

Investigation Findings:
13On May 2, 2023 at 11:10 am, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an unannounced inspection to the facility to deliver the findings of the above allegations. LPA met with Destinee Gastelum. LPA conducted an inspection of the facility on November 30, 2022, at 09:10 am and no immediate deficiencies were observed. Three of four children (C1, C2, C3, C4), four staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that staff #1 (S1) kicked and yelled at C1 and S1 used inappropriate language towards C1. Confidential staff interviews reported that S1 attempted to wake up C1, to get ready because C1 had pre-scheduled therapy appointment. Confidential staff interviews reported that staff#2 (S2) attempted to wake up C1 but again refused. Confidential interviews reported that C1 then woke up upset and broken the facility phone. Confidential staff interviews reported that C1 was provided space to calm down, in which C1 had no further issues. Other interviews reported that staff did not uses any physical restraint with C1 and staff did not use any inappropriate language towards C1. LPA attempted to interview C1 on two separate occasions, however C1 refused to be interviews. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: THE REFUGE, CHILDREN OF THE IMMACULATE HEARTFACILITY NUMBER: VISIT DATE: 05/02/2023

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

met_with: Destinee Gastelum


facility_name: TIFFANY'S PLACE

raw_content:
Narrative:
some group meetings or activities are conducted off site. It was advised that due to the location of the group, clients are expected to be ready to leave the facility 30 minutes prior to the beginning of the session. Staff members stated that clients are fully aware of the rules. Staff stated that that would be only reason that clients are not allowed to attend group. Information from confidential interviews stated that staff do not allow clients to attend group for small issues. It was advised that staff are too strict on the clients, even though the rules are often communicated. Information from additional witnesses stated no concerns have been advised regarding clients not being allowed to attend group. It was reported that participation is high for the facility. It was reported that a client was not allowed to be permitted back into the facility after they returned from AWOL. It was advised by Administrator that the client went on AWOL status during the Covid-19 pandemic and guidelines were put in place. It was advised that upon client's return to the facility, a mandatory quarantine must take place. It was advised that the client refuse to go on quarantine status until a negative Covid-19 test returned. It was stated that staff members contacted the probation department and was advised to transport the client to the juvenile facility in order for the client to be detained and quarantine at the facility. It was advised that the next day, the clients probation officer contacted the facility and did not agree with the decision; the client never returned to the facility. Information from confidential interviews stated thaty facility staff refused to allow client into the home and subsequently had to go to juvenile hall. No further information was advised. Additional witnesses stated they had no further concerns due to the facility being advised to act accordingly. Further information stated the decision was made to ensure the safety of the facility was not jeopardized. In regards to the mental and psychiatric needs of the clients not being met, it was advised that clients are referred to mental and psychiatric health to two outside clinics. It was reported that due to the pandemic, appointments were made slower than normal. It was advised that clients are allowed to speak with the facililty social worker and their own therapist. It was reported that clients are provided their psychotropic medication on a regular and scheduled basis. Information from confidential interviews stated clients did not feels supported during the pandemic by staff or therapist. It was also reported tha appointments took too long to schedule. It was also advised that some staff were sensitive to the needs of clients and ensured they were safe and comfortable. Probation officer and social worker stated there were no issues or concerns as clients are taken to therapeutic services regularly. It was also advised that no concerns were advised or addressed. In regards to staff being rough with minor, it was reported that a staff member "snatched" a jacket out of a client's hand. It was advised that no concerns were ever addressed pertaining to a staff member being rough or inappropriate with a client. It was advised that the facility is completely "hands off." Confidential interviews stated a staff member was rough with a client. It was reported that a staff member "snatched" a remote control out of a client's hand. Physical discipline and any other incident was denied. Additional witnesses stated no issues or concerns were advised regarding staff being "rough" with clients. It was reported that client did not have enough clothes and was not taken shopping. It was advised that San Diego County placements do not receive clothing allowance. It was reported that facility abides by the guidelines of San Diego County's clothing standard. It was advised that the inventory is conducted monthly and clients are allowed to shop with their peer counselor to meet the standard if the inventory is deficient. It was advised that due to the pandemic, shopping was conducted online. LPA Harris was provided clothing receipts and inventory documents. Confidential interviews stated that the clients have been placed at the facility and have not had any clothes purchased for them. It was reported that clients are also not allowed to do any online shopping with their peer counselor. It was reported that representatives are aware of the concerns. Information obtained from additional witnesses stated clients have an abundance of clothing. It was advised that clients always have clean and appropriate clothing on when observed; no concerns have been advised. In regards to the allegation that staff took minor's computer away, it was reported that staff do not allow clients to utilize their personal computers. Administrator advised that due to the CSEC population the facility houses, the clients are not allowed access to computers, phones, social media applications, etc. Administrator stated due to the Covid-19 pandemic, clients were required to utilize computers to complete schoolwork. It was reported that clients were abusing their computer privileges by downloading music and social media applications. Administration stated in order to combat the issues and ensure the clients are not being revictimized, the clients were switched to paper schoolwork packets. Administration stated therefore; the clients are no longer permitted to use computers. Confidential interviews stated staff took away thier computers due to clients not following the rules, but the computers were needed in order to complete school work. Information from the interviews also stated that it is not a privilege, but a right to have access to technology. Information from confidential interviews corroborated that due to the nature of the clients' past, clients are not permitted to have access to technological devices; no concerns. Based on interviews and information obtained, the allegations that staff did not allow minor to go to youth group, minor was not allowed back to the group home after minor had went on absent without leave (AWOL) status, mental and psychiatric needs of minors are not being met, minor does not have enough clothes, staff was rough with minor, and staff took minor's computer away, may or may not have occurred, however it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. Exit interview conducted and a copy of the report will be provided to the representative. Signed copies will be placed in the complaint file.

Investigation Findings:
13Licensing Program Analyst (LPA) Jazmond Harris provided the findings for investigation pertaining to the listed allegations to Facility Administrator, Briann Guillen via phone, due to the Covid 19 pandemic. On January 13, 2021 at 1: PM, LPA N. Strickland initiated the complaint investigation with CEO, Lynn Burgard and no immediate deficiencies or health concerns were noted. LPA Harris conducted interviews with Administrator, Facility Manager, Staff Members, Social Worker, Michelle White, Probation Officer, and two out of three clients (C1, C2, C3). One client refused to be interviewed by LPA Harris. On January 7, 2021, Community Care Licensing (CCL), received information which stated staff did not allow minor to go to youth group, minor was not allowed back to the group home after minor had went on absent without leave (AWOL) status, mental and psychiatric needs of minors are not being met, minor does not have enough clothes, staff was rough with minor, and staff took minor's computer away. In regards to staff not allowing minor to go to youth group, it was advised by administration and staff that UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Jazmond D Harris 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: TIFFANY'S PLACEFACILITY NUMBER: VISIT DATE: 05/25/2021

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

met_with: Facility Administrator-Briann Guillen


raw_content:
Narrative:
CEO stated that she used the word for clarification, but never called Client #1 the term. Information obtained from confidential interviews stated that no client has been called the term, but information advised stated that staff has told clients to "stop having a black attitude." It was reported that the facility did not have any food and that clients were forced to eat biscuits for dinner. It was advised by administration and staff that the facility has more than enough food. It was advised that the facility's food supply is replenished on Tuesdays and Saturdays. It was also stated that the facility obliges by the Community Care Licensing Standard for perishable and non perishable foods. Confidential interviews revealed that the facility has enough food and clients are fed well, but a lot of the food is expired. It was reported that minors are denied television usage and are taken on inappropriate outings. It was stated that clients are only allowed to watch documentaries and were taken to a cemetery for an outing. It was stated that clients do have media education time where they do what documentaries, but are able to watch their own shows at another time. Confidential interviews did not reveal any issues or concerns regarding television time. It was also reported that clients were taken to a cemetery for an outing. Information obtained from administration and staff denied the allegation. It was reported that clients are taken to parks, beaches, movies, etc. Information from confidential interviews corroborated the information. It was reported that the facility is dirty and has pest. Information obtained stated that staff members and clients are responsible to clean the facility. It was also reported that a cleaning company cleans the facility once a month. It was reported that the facility can get messy, but never dirty. No information was advised of the facility having pest. Information obtained from confidential interviews stated that the facility is dirty; especially the kitchen and refrigerator. Information did advise that staff and clients are responsible for cleaning the facility. Confidential information did state that pest are in the facility as well. It was reported that a staff did not keep minors personal information confidential. It was reported that recently a client did advise that a staff member revealed their medical information. Information from administration and staff stated that Client #1 told a new client their medical information which was corroborated by the new client. All staff denied that they shared any personal information regarding any client. Information obtained from confidential interviews stated staff do share their information, but could not provide any specific details. Based on interviews and information obtained, the allegations that staff made inappropriate comments towards minor, staff did not maintain adequate food supply on premises, staff did not provide enough allowance to youth, minors denied tv usage, minors taken on inappropriate outings, facility is dirty and has pests, and staff did not keep minors personal information confidential may or may not have occurred, however it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. Exit interview conducted and a copy of the report will be provided the facility.

Investigation Findings:
13On June 16, 2021 at 5: PM, Licensing Program Analyst (LPA) Jazmond Harris met with Facility Social Worker, Michelle White to provide the findings for the investigation pertaining to the listed allegations. On January 15, 2021, at 1: PM, LPA Nicole Strickland initiated the complaint investigation with CEO and no immediate deficiencies were noted. LPA Harris conducted interviews with Administrator, Facility Managers, Probation Officer, and two out of four clients (See Confidential Names List (LIC 811) dated June 14, 2021. LPA Harris was not able to interview two clients due to no current contact information being available. On January 7, 2021, Community Care Licensing (CCL), received information which stated staff made inappropriate comments towards minor, staff did not maintain adequate food supply on premises, staff did not provide enough allowance to youth, minors denied tv usage, minors taken on inappropriate outings, facility is dirty and has pests, and staff did not keep minors personal information confidential. It was reported that a staff member called a client a "nigger." Information obtained from administration and staff stated that Client #1 uses the derogatory term often towards clients and staff. It was advised that CEO had a discussion with Client #1 and stated that the term should not be used towards anyone in the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Jazmond D Harris 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: TIFFANY'S PLACEFACILITY NUMBER: VISIT DATE: 06/16/2021

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

met_with: Facility Social Worker-Michelle White


raw_content:
Narrative:
On May 10, 2021, the Department received allegations that facility did not notify clients and staff of exposure to COVID-19 and staff were not wearing face coverings inside the facility. Confidential interviews revealed that there was a COVID-19 positive individual in the facility, at which time the staff and the residents were not notify of possible exposure. Additional confidential interviews revealed that all in person appointments and outing were canceled, and clients were quarantine without any explanation. Confidential interviews revealed that staff have not been wearing face coverings since January of 2021. Additional interviews revealed that staff are told to wear face coverings when personnel from Child Welfare Services, Probations, and/or Community Care Licensing arrive to the facility. Based on confidential interviews and documentation reviewed the allegations that the facility did not notify clients and staff of exposure to COVID-19 and staff are not wearing face coverings in the facility are substantiated. This poses a potential health, safety and personal rights risk of harm to clients placed in care. The facility is being issued a citation in accordance with the Health and safety Code Health and safety Code section 1550 for conduct inimical . See page LIC809d for the cited deficiencies. An exit interview was conducted, and appeal rights discussed. Exit interview conducted and a copy of this report, LIC811 and appeal rights were given to the PA Guillen for signature.

Investigation Findings:
13On August 31, 2021 at 9: AM, Licensing Program Analysts (LPAs) Gloria Meza-Gonzalez and LPA Danielle Garcia conducted an unannounced complaint inspection at the facility. LPA Meza-Gonzalez met with program Administrator (PA) BriAnn Guillen to discuss and deliver the investigative findings for the allegations noted above. LPA Meza-Gonzalez conducted an unannounced inspection with the facility on May 19, 2021. No safety concerns were observed. During the investigation, LPA Meza-Gonzalez interviewed three clients (Client #1 [C1] , Client #2 [C2], Client #3 [C3]) and six out of seven staff (Staff #1 [S1], Staff #2 [S2], Staff #3 [S3], Staff #4 [S4], Staff #5 [S5], Staff #6 [S6]), Program Administrator (PA), Agency Social Worker, and County Social Worker (see confidential name list, LIC811, dated 08/31/2021), LPA Meza-Gonzalez reviewed the following documentation: Special Incident Reports (SIRs), staff roster, clients' face sheets, and needs and service plans. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Gloria Meza-Gonzalez 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 08-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, METROPOLITAN DR. # FACILITY NAME: TIFFANY'S PLACEFACILITY NUMBER: VISIT DATE: 08/31/2021

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

met_with: BriAnn Guillen


raw_content:
Narrative:
On May 17, 2021, Community Care Licensing (CCL) received an allegation that the S1 inappropriately grabbed C1 while in care. Confidential interviews revealed inconsistencies regarding S1 grabbing C1. Confidential interviews revealed that S1 grabbed C1 aggressively to get C1 out of the med closet. Additional confidential interviews reported that C1's arm touched S1's open hand as S1 was turning around from the med closet. There were no witnesses to this incident. Based on confidential interviews and record review, although the allegations that S1 inappropriately grabbed a C1 while in care may or may not have occurred, the allegation is not supported or proven by the evidence gathered. Therefore, the allegation is determined to be unsubstantiated. An exit interview was conducted, a copy of this report, the appeals and LIC 811 were given to PA Guillen.

Investigation Findings:
13On August 31, 2021 at 11: AM, Licensing Program Analysts (LPAs) Gloria Meza-Gonzalez and Danielle Garcia conducted an unannounced complaint inspection at the facility. LPA Meza-Gonzalez met with Program Administrator (PA) BriAnn Guillen to discuss and deliver the investigative findings for the allegations noted above. LPA Meza-Gonzalez conducted an unannounced inspection with the facility on May 19, 2021. No safety concerns were observed. During the investigation, LPA Meza-Gonzalez interviewed three clients (Client #1 [C1] , Client #2 [C2], Client #3 [C3]) and five out of six staff (Staff #1 [S1], Staff #2 [S2], Staff #3 [S3], Staff #4 [S4], Staff #5 [S5]), Program Administrator (PA), Agency Social Worker, and County Social Worker (see confidential name list, LIC811, dated 08/31/2021), LPA Meza-Gonzalez reviewed the following documentation: Special Incident Reports (SIRs), staff roster, C1's face sheet, and C1's needs and service plan. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Gloria Meza-Gonzalez 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 08-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, METROPOLITAN DR. # FACILITY NAME: TIFFANY'S PLACEFACILITY NUMBER: VISIT DATE: 08/31/2021

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


raw_content:
Narrative:
On 05/17/2021, Community Care Licensing (CCL) received an allegation that the S1 did not transport minor in a safe manner. Confidential interviews revealed that C1 and C3 were in the vehicle with S1, when S1 hit a parked vehicle while backing up. Additional information revealed that S1 did not stop to access the damages, wait for the owner of the vehicle or leave contact information. S1 contacted CEO once S1 arrived at the facility to inform CEO about the car accident. CEO went to the scene of the accident to access the damages and provide contact information. Based on confidential interviews and documentation reviewed the allegation that S1 did not transport minor in a safe manner is substantiated. This poses a potential health, safety and personal rights risk of harm to clients placed in care. The facility is being issued a citation in accordance with the Title 22, Division 6, Chapter 1: Responsibility for Providing Care and Supervision section code 80078 (a). See page LIC809d for the cited deficiencies. An exit interview was conducted, and appeal rights discussed. Exit interview conducted and a copy of this report, LIC811 and appeal rights were given to the PA Brooks for signature.

Investigation Findings:
13On 10/15/2021 at 9: AM, Licensing Program Analyst (LPA) Gloria Meza-Gonzalez conducted an unannounced complaint inspection at the facility. LPA Meza-Gonzalez met with Program Administrator (PA2) Rushel Brooks to discuss and deliver the investigative findings for the allegation noted above. LPA Meza-Gonzalez conducted an unannounced inspection with the facility on May 19, 2021. No safety concerns were observed. During the investigation, LPA Meza-Gonzalez interviewed three clients (Client #1 [C1] , Client #2 [C2], Client #3 [C3]) and four out of five staff (Staff #2 [S2], Staff #3 [S3], Staff #4 [S4], Staff #5 [S5]), Program Administrator (PA1) , Agency Social Worker (ASW), Chief Executive Officer (CEO) and County Social Worker (CSW) (see confidential name list, LIC811, dated 10/15/2021). LPA Meza-Gonzalez was not able to interview Staff #1 (S1). LPA Meza-Gonzalez reviewed the following documentation: Special Incident Reports (SIRs), staff roster, and C1 and C2's face sheet. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Gloria Meza-Gonzalez 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 08-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, METROPOLITAN DR. # FACILITY NAME: TIFFANY'S PLACEFACILITY NUMBER: VISIT DATE: 10/15/2021

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

met_with: Rushel Brooks


raw_content:
Narrative:
Confidential interviews revealed staff tried to intervene during the client-on-client altercation by trying to get in between the two clients creating space. Confidential interviews revealed other clients assisted staff by trying to pull one client off the other. Other interviews revealed that C1 did have a scab on their right knee but refused to seek medical treatment from staff. Confidential interviews revealed conflicting statements whether C2 refused, or the facility failed to provide medication on 10/12/21 and 10/13/21. A confidential interview indicated that C2 did not refuse their medications on 10/12/21 and 10/13/21, although the MAR's stated the client missed their medications. Based on interviews conducted and evidence gathered during the investigation, the allegations that staff failed to protect a client in care resulting in injuries and staff failed to give client medication may have occurred, however is not supported, or proven by evidence. Therefore, the allegations are unsubstantiated at this time. A copy of this report, LIC 811, and appeal rights were reviewed and explained to Administrator, Rushel Brooks.

Investigation Findings:
13On 12/09/21 at 9: AM, Licensing Program Analyst (LPA) Danielle Garcia and LPA Gloria Meza-Gonzalez, met with Administrator, Rushel Brooks to deliver the findings regarding the allegations as stated above. During the investigation, Licensing Program Analyst (LPA) Danielle Garcia was able to interview four clients (C1, C2, C3, C4), four staff (S1, S2, S3, S4), the Administrator (A1), the CEO (CEO) of the facility and record review of facility documents (Staff Contact lists and all clients face sheets and needs and services plans, C2's Medications Administration Records (MAR) for 10/12/21 thru 10/13/21, and the Special Incident Reports). On 10/15/21, Community Care Licensing received the allegations that staff failed to protect a client in care resulting in injuries, staff failed to give client medication. ***Continued on Page 2*** UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Danielle Garcia 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 08-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, METROPOLITAN DR. # FACILITY NAME: TIFFANY'S PLACEFACILITY NUMBER: VISIT DATE: 12/09/2021

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


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

raw_content:
Narrative:
All confidential interviews revealed a client was sleeping in the therapy room because it was the only room the client felt safe due to the lock on the door. Confidential interviews revealed the facility implemented an "angry wall" where clients wrote other client's names and profanity on the wall and then used a plastic bat to punch holes into the wall. All interviews revealed conflicting statements on the rules and the purpose of the angry wall. Confidential interviews revealed only one client's name on the angry wall had holes. Based on confidential interviews and record review, the preponderance of evidence standard has been met and the allegations are substantiated. This posed a potential Health, Safety or Personal Rights risk to the clients in care, the facility is being cited for violation of Short Term Residential Therapeutic Program Interim Licensing Standards, Article 07. Physical Environment, Section 87087 (b) (4): Buildings and Grounds and Article 6. Continuing Requirements, Section 87072 (d)(11): Personal Rights. Confidential interviews and record reviews confirm a client was sleeping in a room for therapy and staff is making clients remain in a hostile environment. A copy of this report was reviewed and provided to Administrator Rushel Brooks, along with the Appeal Rights.

Investigation Findings:
13On 12/09/21 at 9: AM, Licensing Program Analyst (LPA) Danielle Garcia and LPA Gloria Meza-Gonzalez, met with Administrator, Rushel Brooks to deliver the findings regarding the allegation as stated above. During the investigation, Licensing Program Analyst (LPA) Danielle Garcia was able to interview four residents (C1, C2, C3, C4), four staff (S1, S2, S3, S4), the Administrator (A1), the CEO (CEO) of the facility and record review of facility documents (Staff Contact lists and all clients face sheets and needs and services plans, C2's Medications Administration Records (MAR) for 10/12/21 thru 10/13/21, and the Special Incident Reports). On 10/15/21, Community Care Licensing received the allegations that a client is sleeping in a room used for therapy and staff is making clients live in a hostile environment ***Continued on page 2*** SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Danielle Garcia 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 08-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, METROPOLITAN DR. # FACILITY NAME: TIFFANY'S PLACEFACILITY NUMBER: VISIT DATE: 12/09/2021

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

Deficiencies:
87087: Buildings and Grounds
No room commonly used for other purposes shall be used as a bedroom

title: (b) (4)


raw_content:
Narrative:
Specifically, it was reported S1 and S2 knew the C1 and C2 were bringing in alcohol [to the facility] and did nothing about it. Confidential interviews provided consistent reports of C1 and C2 bringing alcohol into the facility. Confidential interviews provided consistent statements of staff finding multiple empty bottles of alcohol in trash cans, in bushes, or other places at the facility. Confidential interviews also provided consistent statements regarding C1 and C2 drinking the alcohol in the presence of Staff #1 (S1), S2, and Staff #8 [S8] without staff intervention. CCL received and additional allegation alleging Staff (Staff #1 [S1]) provided minors (Child #1 [C1] and Child #2 [C2]) with vape pens. Confidential interview provided consistent statements regarding the use of vape pens by residents in the facility. Confidential interviews revealed consistent statements of S1 would vape with C1 and C2, and providing vape pens to C1 and C2. Based on confidential interviews the allegations of staff (Staff #2 [S2] and Staff #3 [S3]) negligence resulted in minors (Child #1 [C1] and Child #2 [C2]) consuming alcohol and Staff (Staff #1 [S1]) provided minors (Child #1 [C1] and Child #2 [C2]) with vape pens are substantiated. The preponderance of evidence standard has been met. Facility is cited for violation of California Code of Regulations regulation 80078(a) Responsibility for providing care and supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs, and Interim Licensing Standards (ILS) standard 87072(d) Personal Rights (d) The licensee shall ensure that each child, regardless of whether the child is in foster care, is accorded the personal rights specified in Welfare and Institutions Code Sections 16001.9 as applicable. In addition, the licensee shall ensure that each child is accorded the following personal rights. A copy of the report was discussed and provided along with appeal rights to Tiffany's Place Administrator (ADM), Rushel Brooks. regarding how residents AWOLing is handled by staff. Confidential interviews reported when a resident attempts to AWOL from the facility emergency intervention techniques are used by staff. Confidential interviews and record review revealed anytime a resident walks off or is out of staff sight while on outings this action is considered a resident AWOLing. Confidential interviews reported C1 had a history of walking off and/or being out of staff sight both from the facility and while on outings however, how staff handled the walk-offs is unknown. Confidential interviews could not confirm or dispute that staff followed emergency intervention plan when residents AWOLed. CCL received an additional allegation alleging Staff (Staff #3 [S3]) did not adhere to facility dress code allowing minors to wear provocative clothing. Confidential interviews provided conflicting reports of residents being allowed to wear provocative clothing. Confidential interviews reported when residents are leaving the facility for outings staff remind residents to adhere to dress code in order to participate in the outing. Additionally it was reported if residents are in the facility depending on which staff is working dress code may or may not be enforced. Based on confidential interviews and record review the allegations of staff (Staff #2 [S2] and Staff #3 [S3]) did not follow Emergency Intervention plan when minors (Child #1 [C1] and Child #2 [C2]) AWOL'd from the facility and Staff (Staff #3 [S3]) did not adhere to facility dress code allowing minors to wear provocative clothing, may or may not have occurred, however it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of the report was provided along with appeal rights to Tiffany's Place Administrator (ADM), Rushel Brooks.

Investigation Findings:
13On January 6, 2022 at 3:35pm Licensing Program Analyst (LPA), Nicole Strickland, met with Tiffany's Place Administrator (ADM), Rushel Brooks, to deliver the findings for the above stated allegations. LPA conducted an inspection of the facility on May 18, 2021 at approximately 4:00 pm and no immediate deficiencies were observed. The investigation was conducted by Special Investigator (SI) Lucius Charlemagne and LPA Strickland and included interviews with three of four foster children (Child #1 [C1], Child #2 [C2], and Child #4 [C4]), Probation Officer (PO) two current staff members (Staff #3 [S3], Staff #4 [S4]), five former staff member (Staff #2 [S2], Staff #5 [S5], Staff #6 [S6], Staff #7 [S7], and Staff #8 [S8]). Two confidential witnesses did not respond to SI and LPA's request for an interview and therefore were not interviewed. In addition, county records and facility records were reviewed. On May 12, 2021, Community Care Licensing (CCL) received an allegation alleging staff (Staff #1 [S1] and Staff #2 [S2]) negligence resulted in minors (Child #1 [C1] and Child #2 [C2]) consuming alcohol. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Nicole Strickland 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: TIFFANY'S PLACEFACILITY NUMBER: VISIT DATE: 01/06/2022

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:


summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Brian Bertoli met with Administrator Brittany Burns regarding a complaint investigation at the Short Term Residential Therapeutic Program. The purpose of the inspection was to deliver the findings for the above allegation. During the course of the investigation, LPA Bertoli inspected the facility, interviewed 3 youth, 4 staff, and 2 social workers, and reviewed documentation. LPA confirmed through interviews with staff and clients that staff engaged in a struggle with client C1 (see LIC 811 dated 10/29/21) over possession of a blanket that C1 wanted to take outside to keep warm. It was also confirmed by interviews with staff and clients and Incident Reports that doors were removed from client's bedrooms. Based on the information obtained, there is a preponderance of the evidence to prove that staff violated personal rights of clients. Therefore, the above allegation is substantiated. Title 22 deficiencies were cited regarding the struggle with the blanket and an Advisory Note was issued regarding door removal. Appeal Rights were provided and discussed with the facility. An exit interview was conducted and a copy of the report was left with the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: Brian Bertoli 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 21-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, GOLF COURSE DR. STE. A- ROHNERT PARK, CA FACILITY NAME: TLC CHILD AND FAMILY SERVICES-ORCHARD HOUSEFACILITY NUMBER: 496801036

met_with: Brittany Burns


raw_content:
Narrative:
Appeal Rights were provided and discussed, and no deficiencies were cited. An exit interview was conducted and a copy of the report was given to the facility. This department has investigated the allegations, and although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the Staff threaten a client or yelled at a client; therefore, the above allegations are unsubstantiated.

Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Brian Bertoli met with Administrator Brittany Burns regarding a complaint investigation at the STRTP. The purpose of the inspection was to deliver the findings for the above allegations. During the course of the investigation, LPA Bertoli inspected the facility, interviewed 5 youth, 5 staff, and 1 social worker, and reviewed documentation. The alleged victim, C5 (see LIC811 dated 3/24/22) was not able to identify staff that were involved. Other than C5, none of the clients or staff said that they had witnessed or knew of the allegations occuring to C5. The Investigating Social Worker also acknowledged the same result. LPA Bertoli was unable to determine if staff threatened client or yelled at client C5. There is a lack of clear evidence to make a determination as to whether a regulatory violation did occur. (continued on LIC9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: Brian Bertoli 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 21-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, NEOTOMAS AVENUE, STE. FACILITY NAME: TLC CHILD AND FAMILY SERVICES-ORCHARD HOUSEFACILITY NUMBER: VISIT DATE: 03/24/2022


raw_content:
Narrative:
This department has investigated the allegations, and although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the staff handled minor in a rough manner or sprayed minor with chemicals; therefore, the above allegations are unsubstantiated. Appeal Rights were provided and discussed, and no deficiencies were cited. An exit interview was conducted and a copy of the report was given to the facility.

Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Brian Bertoli met with Administrator Brittany Burns regarding a complaint investigation at the STRTP. The purpose of the inspection was to deliver the findings for the above allegations. During the course of the investigation, LPA Bertoli inspected the facility, interviewed youth and staff, and reviewed documentation. None of the youth or staff had knowledge of any youth being handled in a rough manner. Staff and youth acknowledged that one youth was sprayed with water when they were playing in the laundry room. LPA Bertoli was unable to determine if staff handled minor in a rough manner or sprayed minor with chemicals. There is a lack of clear evidence to make a determination as to whether a regulatory violation did occur. (continued on LIC9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Mendoza LICENSING EVALUATOR NAME: Brian Bertoli 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 21-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, NEOTOMAS AVENUE, STE. FACILITY NAME: TLC CHILD AND FAMILY SERVICES-ORCHARD HOUSEFACILITY NUMBER: VISIT DATE: 01/26/2023


facility_name: TLC CHILD AND FAMILY SERVICES-ORCHARD HOUSE

summary: Facility Evaluation

raw_content:
Narrative:
An announced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Joel Segura on 06/09/2021 at 3:00pm. This inspection was conducted via MS Teams due to COVID19 restrictions on conducting on site inspections at licensed facilities. LPA Segura conducted SB Psychotropic Medication interviews on 06/08/2021 at 1:30pm with three staff , Administrator Brittany Burns, Medical Coordinator Dania Dudley and Facility Manager Janae Baddeley . At 3pm on todays date LPA Segura and Medical Coordinator Dania Dudley, counted medications and verified PMAR and centrally stored medication logs for three children. Dania also assisted with a physical plant inspection of the facility. No deficiencies were observed during this tele-inspection. A follow up inspection will be conducted to interview clients on 06/10/2020. LPA Segura provided this report to the administrator via email for signature and acknowledgment the report was received.

visit_type: Case Management

met_with: Dania Dudley


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Brian Bertoli and David Hiett conducted an unannounced inspection for the purposes of completing an Annual/Required Inspection and met with administrator Brittany Burns. Also assisting with records and the inspection were Treatment Director Karen Bergman and Operations Manager James Freeman and others. A pre-screening call was done prior to arrival, and Administrator Burns indicated that no one was Covid positive, symptomatic, or had known exposure. However, upon arrival it was disclosed that two youth had just become symptomatic overnight. Appropriate protocols were followed in the facility for the inspection and all interviews were conducted outdoors. The Physical Plant was toured inside and out by LPA Bertoli. Water temperatures were measured at 110 degrees. Seven-day Non-perishable food supply was inspected and was found to be adequate. Two-day perishable food supply was inspected and were found to be adequate and consistent with the menu. LPA inspected bedrooms and found that there was adequate linens and each bed had mattress pads. The home is clean and in good repair. There are no firearms in the facility. There are no open bodies of water on the property. Medications are locked in the office. Toxics and cleaning solutions are locked in the laundry room. Required documents are posted. Disaster drills are conducted quarterly, there are charged operable fire extinguishers, carbon monoxide and smoke detectors are in the facility. Five clients and four staff were interviewed. Client files were partially reviewed at the administration office and will be completed on another date. Per Title Regulations, no deficiencies were cited during this inspection. Advisory notes were issued for the Disaster Plan, however those issued for HSC 1565(c) and CCR 80023(d)(2) do not apply, as documentation of compliance was received after they were saved on the system. An exit interview was conducted and a copy of the report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Brian Bertoli conducted an unannounced inspection for the purposes of completing an Annual/Required Continuation Inspection and met with Administrator Brittany Burns. Assisting with records was Executive Assistant Jessica Quigley. A pre-screening call was done with Administrator Burns prior to arrival, and there were no changes since last visit, but advised they may have updates during the day. The records were reviewed at the administrative office and no further updates occurred. Staff records were reviewed and found to be acceptable. LPA Bertoli also reviewed Emergency Interventions, and Core Therapeutic Services were reviewed with Clinical Director Reese Clark. Per Title Regulations, no deficiencies were cited during this inspection. An exit interview was conducted and a copy of the report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) Brian Bertoli and David Hiett conducted an unannounced inspection for the purposes of completing an Annual/Required Continuation Inspection and met with Administrator Brittany Burns. Assisting with records was Executive Assistant Jessica Quigley. A pre-screening call was done with Administrator Burns prior to arrival, and there were no changes since last visit. The records were reviewed at the administrative office. Client records were reviewed and found to be acceptable. A Technical Advisory was issued for ILS 87070(c)(1). The Annual/Required inspection is complete. Per Title Regulations, no deficiencies were cited during this inspection. An exit interview was conducted and a copy of the report was left at the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA) Brian Bertoli made an announced visit to the facility for the purpose of reviewing the remodeling plans for the 'Phoenix House' portion of the facility. LPA Bertoli met with Administrator Brittany Burns, who assisted with the inspection. A COVID pre-screening call was made prior to the visit, and there were no known cases, exposures, or symptomatic youth or staff. LPA Bertoli toured the facility, reviewed plans, and discussed the nature of the changes and the potential impact on the youth. The youth that were previously in 'Phoenix' will be housed in the 'Orchard House' portion of the facility, which has eight bedrooms. The two houses combined constitute the licensed facility, which has a capacity of 16. The facility is converting two bedrooms to office spaces for the Facility Manager and the Medication Coordinator/Nurses office. The home will have eight bedrooms remaining, and they will not have more than six youth at a time in the home. The remodeling is expected to take approximately 3 months. LPA Bertoli has determined that the modifications to the facility are acceptable for the Short-Term Residential Therapy Program. No Title 22 deficiencies were found on this visit. An exit interview was conducted with Administrator Burns and a copy of this report was given to the Administrator.


facility_name: TMHA-YOUTH TREATMENT PROGRAM

raw_content:
Investigation Findings:
13On 9/25/2024 at 4:00pm Licensing Program Analyst (LPA) Enrique Hernandez made an unannounced inspection to the above facility for the purpose of concluding the investigation on the above allegation and deliver the finding. LPA spoke with Allison Jensen Facility Administrator and together, discussed the investigative finding. During the investigative process by Licensing program Analyst (LPA), Enrique Hernandez, all relevant parties have been accounted for. It was reported that a Staff did not provide adequate supervision resulting in minor being sexually assaulted by another minor in care. LPA Hernandez could not interview Client 1 (C1) because C1 had left the facility. LPA intended to contact C1 via the phone provided by the social worker, but it was disconnected. Lastly, statements alleging minor being sexually assaulted by another minor in care were not corroborated during the investigation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. No deficiencies are being cited at this time. Exit interview was conducted, and due to technical difficulties with the printer, a copy of this report will be emailed. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Allison Jensen/Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 02/06/24 at 09: AM Licensing Program Analyst (LPA) Jhane Haynes made an announced visit to the above facility for the purpose of conducting a pre-licensing inspection. LPA met with Program Manager(PM) Alley Jensen who granted access to the facility. Together LPA and PM toured the home inside and out. This is a six bedroom, four bathroom single-story home with barn access in rural area. There are no swimming pools or bodies of water of the premises. LPA observed the following during facility tour: Entry: contains required postings, rug, and entry to staff office. Staff Office will have Dutch door to administer medications. Garage will be a space for on site visits, containing space for computers, door leading to storage space will have emergency food supplies and door to building exterior. Water heater is located her. Left Hallway contains locked storage closet that will hold chemicals. Leads to three client bedrooms, linen closet and staff hallway. Bedroom #1 contains adequate closet space. Bathroom#1 contains functioning toilet, double sinks and shower with running water. Bedroom #2 contains adequate closet space. Bedroom #3 contains adequate closet space. Staff Hallway leads to two office spaces, laundry area and bathroom. (Continued on LIC809-C) Office #1 will be reserved for individual/family therapy. It is equipped with soundproofing tiles and door leading to exterior. Office #2 contains cabinets for locked medications. Laundry Space will contain washer and dryer. Bathroom #3 contains functioning toilet, sink and shower with running water. Living Room contains adequate seating for clients, rug, fireplace that is inaccessible to clients. Switch is in locked office. Kitchen/Dining contains center island with three chairs, dishwasher, four burner stove and oven in operating condition, refrigerator and microwave. Adjacent to the refrigerator is a walk in pantry. There are sliding glass door that leads to exterior. Right Hallway leads to three client bedrooms, bathroom and sensory room. Bathroom #4 contains functioning toilet, double sinks and shower with running water. Breakout/Sensory Room contains large chair and soundproof tiles. Clients will be able to make phone calls here. Bedroom #4 contains adequate closet space. Bedroom #5 contains adequate closet space. Bedroom #6 contains adequate closet space. Fire and carbon monoxide alarms were tested and in working condition. Stations where fire extinguishers will be placed are located throughout the facility. Exterior opens up to large green area, there are tables and chairs, small fountain, and tortoise cage. Left side of property houses solar panels that a fence will be places and standing wells of the far side of property which ladder will be locked. 1/3 of Barn contains office, bathroom and space reserved for group and CFT meetings. There is an door leading to exterior. Two-thirds of the barn is rented out to staging company who does not have access to facility. Bathroom #5 located in barn contains sink and toilet. Due to early inspection, LPA will return once staff office is complete and furniture has been moved in to complete process. An exit interview was conducted and a copy of this report was left with Program Manager.

visit_type: Prelicensing

met_with: Alley Jensen Program Manager(PM)


summary: Facility Evaluation

raw_content:
Narrative:
On 03/26/24 at 11:22AM Licensing Program Analyst (LPA) Jhane Haynes and Licensing Program Manager (LPM) Kevin Sauk arrived at the above facility for the purpose of conducting a pre-licensing inspection. LPA met with Facility Administrator (FA) Alley Jensen who granted access and together provided a tour. LPA and LPM observed new fencing outlined around the facility to separate buildings and solar panels. The six-foot fencing surrounding the exterior property line is pending completion. Wells observed to be locked and inaccessible. Staff office has Dutch door fully installed. Countertops in garage space have been installed for client usage. Company leasing 2/3 of the barn had moved out and will be replaced by another renter for storage. LPA will return post-complete facility move in. No deficiencies will be cited today. An exit interview was conducted and copy of the report will be emailed to facility administrator.

met_with: Alley Jensen Facility Administrator (FA)