summary: Facility Evaluation

raw_content:
Narrative:
On March 14, 2025 at 1: PM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced visit to the above facility for the purpose of conducting an annual inspection and met with Joceyln Irasusta, Administrator. LPA inspected the facility's physical plant, including personal rights postings, health-related services, buildings and grounds, food services, telephones, indoor and outdoor activity space, and furniture, fixtures, equipment and supplies. The home is clean, in good repair, and free from observable risks to clients' health, safety, and personal rights. The home is a one story building with three client bedrooms and two client bathrooms which are set up as follows: Bedroom #1 has two twin beds and sleeps two clients, bedroom #2 has one twin bed and sleeps one client, and bedroom #3 has one twin bed and sleeps one client. There is a comfortable family and TV room in the front of the home, kitchen and living room area, multiple locked storage closets, and backyard/patio with table for confidential interviews. LPA reviewed the facility's disaster preparedness plan and staff training, which included all the required information and records. LPA reviewed two client files (C1-C2), which are kept in a locked cabinet. The client files reviewed contain required information and records, including pre-placement screenings, personal rights and facility policy acknowledgements, and medication logs. Due to time constraints, the annual is being extended to complete client and staff file reviews, as well as staff interviews. An exit interview was conducted and a signed copy of this report was provided to Joceyln Irasusta, Licensee.

met_with: Joceyln Irasusta, Administrator


state: CA

facility_name: JOY'S SPECIAL CARE, LLC

summary: Facility Evaluation

raw_content:
Narrative:
On March 24, 2025 at 9: AM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced visit to the above facility and met with Joceyln Irasusta, Administrator. The purpose of this Case Management inspection is to conduct an annual continuation from 3/14/2025. LPA conducted one staff interview. LPA reviewed two client files (C3-C4), which are kept in a locked cabinet. The client files reviewed contain required information and records, including pre-placement screenings, personal rights and facility policy acknowledgements, medication logs, and court authorization for psychotropic medications. LPA reviewed staff files (S1-S5), which contain the required background clearance and demographic information, health screenings, and qualifications. Based on observations made during the inspection, there were no deficiencies cited at this time. An exit interview was conducted with Joceyln Irasusta, Administrator and a signed copy of this report was provided.

report_type: Facility Evaluation

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On July 31, 2025, at 2: PM, Licensing Program Analyst (LPA) Jacob Salem conducted an announced case management visit at the above facility. LPA Salem met with Christian Irasusta, Lead Direct Support Professional. The purpose of the case management visit was to amend findings. A signed copy of this report was provided to Christian Irasusta, Lead Direct Support Professional.


summary: Facility Evaluation

raw_content:
Narrative:
On March 26, 2026, at 8: AM, Licensing Program Analyst (LPA) Jacob Salem conducted an announced case management visit at the above facility. LPA Salem met with Veronica Orsatt, Lead Direct Support Professional. Due to technical difficulties, LPA Salem was unable to complete the visit. A signed copy of this report was provided to Veronica Orsatt, Lead Direct Support Professional.


summary: Facility Evaluation

raw_content:
Narrative:
On April 24, 2026, at 9: AM, Licensing Program Analyst's (LPA) Lucero Jauregui and Stephanie Arreola conducted an unannounced annual/required inspection. LPA's met with Licensee Jocelyn Irasusta. The facility serves four clients. There are currently two clients in placement. There were zero clients present during today's inspection. The facility is a one-story house with three bedrooms, two bathrooms, living room, a kitchen, a dining room, and a garage. The living room is equipped with furniture, television, a table with chairs and toys for the client's use. LPA's observed kitchen to be clean and free from observable hazards. Sharp knives are maintained inaccessible and stored in a locked cabinet under the kitchen sink. LPA's observed seven days of non-perishable food and two days of perishable food. The dining room has a table and four chairs. Additionally, there are couches and a television. Medication cabinet was observed in the kitchen. First aid kit is maintained in medication cabinet and contained all required items. The bedrooms are set up as follows: Bedroom # 1: designated for one client, one twin bed, a nightstand, and closet space. Bedroom #2: designated for one client, one twin bed, a nightstand, and closet space. Bedroom #3: designated for two clients, two beds, two nightstands, and closet space. Bedroom #1 and Bedroom #2 share a bathroom in the hallway. Bedroom #3 has a bathroom. Each room has adequate clean linens, pillows, blankets, comforters, mattress pads, and mattresses. Continued..... A physical plant inspection was conducted. Facility grounds are clean and free from observable hazards. The facility's smoke detectors and carbon monoxide detectors were tested and were observed to be in working order; the fire extinguisher is properly charged and serviced. LPA's observed additional bed linen and towels for clients' use in the hallway closet. There is a washer and dryer in the garage. Chemicals and hazards are maintained locked in garage cabinets and inaccessible to children. Per Licensee there are no weapon's in the home. There is adequate indoor and outdoor activity space. The back patio has a table with chairs, swing for client use and a shed. The shed contains gardening tools and is maintained locked at all times. The hot water temperature was measured at 105 degrees Farenheit. LPA's observed the following items posted: Rights for individuals with Developmental Disabilities, Foster Youth Bill of Rights, meal menu, grievance/complaint policy, visitation policy, house rules, Emergency Disaster Plan LIC610C, planned activities, facility sketch and If You See Something Say Something reporting poster. LPA's reviewed two of two client files and five staff files. Client files are maintained locked in file cabinet in living room area. Staff files are maintained offsite and were readily available for review. LPA Arreola conducted two staff interviews. Based on todays inspection and file review there are no deficiencies observed. An exit interview was conducted, a copy of this report was given to Licensee Joy Irasusta.

visit_type: Annual

met_with: Jocelyn Irasusta, Licensee


facility_name: JULIE'S HOME

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
The preponderance of evidence standard has been met, and therefore the above allegations are found to be substantiated. LPA is issuing a citation of California Code of Regulations, Title 22, Division 6, Chapter 5, Article 6, Section 84078, Subsection (b). See attached LIC 9099-D. LPA informed the licensee that due to a violation resulting in serious bodily injury the Licensing Agency may assess an enhanced civil penalty. Should this occur, the licensee will be notified in writing. An exit interview was conducted, and a copy of this report and the licensee's appeal rights were provided to Facility Manager Mariel Pablo, whose signature on this form confirms receipt.

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

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

report_type: Complaint Investigation

met_with: Facility Manager Mariel Pablo

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

complaint_status: unsubstantiated


raw_content:
Narrative:
Although the allegation may have happened or is valid, based on LPA's observations and interviews, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report and the licensee's appeal rights were provided to Staff Norman Mabulay.

Investigation Findings:
13On 7/18/25, Licensing Program Analyst (LPA) Mariah Hawkins conducted an unannounced complaint investigation visit at the facility. LPA met with Staff Norman Mabulay and informed of the purpose of the visit. The purpose of the visit was to deliver findings for the investigation of the above allegation. LPA conducted 1 confidential interview. Based on all confidential interviews, observations, and record review, the allegation pertains to black bruising around a nonverbal client's eyes. The client had seizure activity a few days prior to the observation of bruising and also engaged in head-banging self-injurious behavior. The client was observed interacting with staff and did not show signs of neglect, abuse, or discomfort around staff. The facility took the client to the hospital in a timely manner in response to the seizure. Facility staff reportedly did not observe the bruising, but upon being made aware of the bruising, staff consulted medical professionals and took the client to the doctor for assessment. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Mariah Hawkins 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 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE FACILITY NAME: JULIE'S HOMEFACILITY NUMBER: VISIT DATE: 07/18/2025

met_with: Staff Norman Mabulay


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Vaishali Singh-Sood conducted an unannounced inspection of the facility on 6/24/2021 at 8: AM. LPA Singh-Sood met with Jane Gano, Administrator. The Group Home is licensed to serve six clients, ages 12-17 years old. The current census is 6 ambulatory clients. The purpose of this inspection was to comply with a regulatory requirement for a yearly required inspection. Adm. took LPA on a walk-through tour of the facility both inside and out. At the time of the inspection, there were 6 clients and 5 staff present. The facility is a single level home, located in San Mateo, CA. The facility consists of five bedrooms, three for clients and two for staff. Staff bedrooms are located in front of the house and are not accessible to clients. There is one bathroom for staff in this area, however it is available to clients if needed. All three client rooms are located in the back of the house with a master bathroom. LPA observed at the time of this inspection, the facility to be clean, safe, and sanitary. LPA observed adequate lighting and space for clothing. The temperature inside the home is 71 degrees Fahrenheit which is in required temperature range, and the water temperature was 117 degrees, which is also in the required range. There was sufficient perishable food for two days and nonperishable food for 7 days. An emergency food supply is kept in the kitchen and garage. Sharps are kept locked in a drawer in the kitchen, and cleaning supplies are kept locked in the garage. The smoke detectors and fire extinguisher are in working order. Nine smoke detectors and two carbon monoxide are all linked in all rooms and hallways located throughout the home. A fire extinguisher is in the kitchen. Medication is stored in locked cabinets in a small office. LPA reviewed the staff and clients files and they had all necessary forms. Four clients are non-verbal, and two speak with very limited ability. However, all clients appeared to be happy with the care they are receiving. The following documents are posted in the facility: facility license, emergency disaster plan, facility sketch, menu, and personal rights. LPA also observed hand sanitizer, lysol and disinfectants in various areas. LPA reviewed the staff and clients files and they had all necessary forms. The Centrally Stored Medication Log and Medication Administration Records were both observed to be in locked cabinets in a small office. A review of Licensing Information System on June 23, 2021 indicates that all facility staff associated to the facility had DOJ, FBI and child abuse index check clearances. There were no deficiencies cited at today's inspection. Exit interview was conducted at 2: PM, and a copy of the report was emailed to Administrator Jane Gano.

met_with: Jane Gano


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Cheyenne McCambridge conducted an unannounced inspection of the facility for the purpose of conducting an Annual/Required inspection. LPA McCambridge met with Administrator Jane Gano. The Group Home is licensed to serve six clients, ages 12-17 years old. The current census is 6 ambulatory clients. Four clients are non-verbal, and two speak with very limited ability LPA McCambridge toured the facility both inside and out. At the time of the inspection, there were no clients and one staff present. The facility is a single level home, located in San Mateo, CA. The facility consists of five bedrooms, three for clients and two for staff. Staff bedrooms are located in front of the house and are not accessible to clients. There is one bathroom for staff in this area, however it is available to clients if needed. All three client rooms are located in the back of the house with a master bathroom. LPA observed at the time of this inspection, the facility to be clean, safe, and sanitary. Required documents are posted throughout the facility. LPA observed adequate lighting and space for clothing. The temperature inside the home is 71 degrees Fahrenheit which is in required temperature range, and the water temperature was 117 degrees, which is also in the required range. There was sufficient perishable food for two days and nonperishable food for 7 days. An emergency food supply is kept in the kitchen and garage. Sharps are kept locked in a drawer in the kitchen, and cleaning supplies are kept locked in the garage. The smoke detectors and fire extinguisher are in working order. Nine smoke detectors and two carbon monoxide are all linked in all rooms and hallways located throughout the home. A fire extinguisher is in the kitchen. Medication is stored in locked cabinets in a small office. LPA reviewed the staff and clients files and observed to be complete and current with all necessary forms. LPA observed medication logs to be updated and current. There were no deficiencies cited at today's inspection. Exit interview was conducted and a copy of the report was emailed to Administrator Jane Gano.


summary: Facility Evaluation

raw_content:
Narrative:
On 6/20/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a required annual inspection. LPA conducted a screening call with Administrator Jane Gano and met on site with Facility Manager Mariel Pablo. Administrator arrived shortly after LPA's arrival. The CARE Inspection Tool was used to complete this inspection. All residents were at school at the start of this visit. The faciity serves a developmentally disabled population. LPA conducted a tour of the facility and grounds, interviewed 2 staff, and reviewed 5 staff files and 5 resident files. Two residents arrived from school during the visit and were observed to be clean and dressed in clean, well-fitting clothes. Residents appeared very comfortable with staff, and staff were very attentive to residents and maintained strong supervision of, and engagement with, residents. LPA observed the facility site and grounds to be clean, organized, and free of hazards. Beds have clean linens, including mattress pads and top and bottom linens. Bedrooms are double-occupancy, and each resident has their own bed. The kitchen and bathroom were both in sanitary condition. Chemicals and dangerous items are locked away where inaccessible to the residents in care. Medications are stored appropriately and administration is logged appropriately. The kitchen is stocked with more than enough food to meet the needs of the residents in care. Hot water measured within permitted range. No deficiency citations were issued at today's visit. An exit interview was conducted, appeal rights discussed, and a copy of this report was left with Administrator Jane Gano, whose signature on this form confirms receipt.

met_with: Administrator Jane Gano


summary: Facility Evaluation

raw_content:
Narrative:
On 7/26/23 at 3PM, Licensing Program Analyst (LPA) Mariah Hawkins and Licensing Program Manager (LPM) met with Administrator Jane Gano and Golden Gate Regional Center Case Manager Martha Tercero. The purpose of the meeting was to discuss the transition plan for residents whose ages exceed the licensed age range. Currently, the facility has 5 residents in care, and three are 18 or older, with one of these residents being age 22. The Licensing agency is not able to approve an age exception for residents 22 or older. The Administrator was previously advised that age exception requests for all residents 18 or older would need to be submitted. As of today, one request has been received, and two are still in progress. Licensee acknowledges that the facility is currently operating out of compliance and agrees to complete the following (refer to LIC Confidential Names): - Licensee will work with R1's authorized representative to locate an adult home placement for resident R1 and transition R1 into new placement within 30 days, by Friday 8/25/23. - If R1 will not be moved to a new placement by 8/25/23, licensee will submit, by 8/25/23, a transition plan to have R1 moved out to an adult placement. - Licensee will submit age exception requests for R2 and R3 with support letters from authorized representatives. These will be submitted by 8/25/23. A copy of this report was provided to Administrator Jane Gano, who agreed to receive a digital copy, sign, and return to LPA.


summary: Facility Evaluation

raw_content:
Narrative:
On 6/14/24, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility for a required annual inspection. LPA met with House Lead Maria Pablo and informed of the purpose of the visit. LPA toured the facility site and inspected facility records. LPA observed the facility to be clean, dangerous items such as knives, chemicals, and medications were stored where only accessible to staff, and the bathroom and kitchen spaces were clean and sanitary. Resident bedrooms were tidy, offered activity space, and personal items were neatly folded and stored in the closets. LPA also observed residents to be dressed in clean, well-fitting clothes. All residents are nonverbal. LPA observed staff provide close supervision and engagement to each resident and to communicate effectively with each other in caring to each resident's needs as they ate lunch, engaged in individual activities, used the bathroom, and returned from school. LPA observed the resident records to be complete with required documentation. A continuation inspection is required to complete the review of personnel records. However, LPA verified that all staff on site have a background clearance and eligibility to work at the facility. As stated above, a continuation visit will be conducted. No deficiencies were observed during today's inspection. An exit interview was conducted, appeal rights were discussed, and a copy of this report was left with House Lead.

met_with: House Lead Maria Pablo


summary: Facility Evaluation

raw_content:
Narrative:
On 6/26/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit to continue the required annual inspection initiated on 6/14/24. LPA met with House Lead Mariel Pablo and informed of the purpose of the visit. LPA observed the facility to be clean and orderly. During visit, LPA conducted interviews with 2 care staff and inspected 5 personnel files. The personnel files were observed to be complete. LPA observed one area in which technical support may be beneficial. See LIC 9102. LPA also reviewed the facility's emergency drill logs and staff schedules. No deficiency citations were issued at today's visit. An exit interview was conducted, appeal rights were provided, and a copy of this report was left with House Lead, whose signature on this form confirms receipt.

met_with: House Lead Mariel Pablo


summary: Facility Evaluation

raw_content:
Narrative:
On November 22, 2024 (11/22/24) at 10AM, the Children's Residential Program San Jose Regional Office held a scheduled office meeting with the licensee at the San Bruno local unit licensing office. The purpose of the meeting was to discuss a recent complaint and the facility's compliance history. In attendance representing the licensing agency were Licensing Program Manager (LPM) Isabel Diego and Licensing Program Analyst (LPA) Mariah Hawkins, and representing the licensee were Administrator Jane Gano and Facility Manager Mariel Pablo. On 10/15/24, the Department of Social Services, Community Care Licensing Division concluded an investigation into the allegations that a child sustained an unexplained injury while in care and that facility staff did not ensure adequate care and supervision was provided to a child in care. The investigation found that non-ambulatory and non-verbal child C1 (See LIC Confidential Names) sustained an arm fracture during a lapse in supervision. C1's care plan and Regional Center case manager indicated that C1 required one to one (1:1) supervision wherein one staff member provides direct care to solely C1. The investigation found that while the supervising staff member was aware of this requirement, they left C1 unattended for a period of approximately 5 minutes in C1's bedroom with the door closed. During this time, C1 sustained a fracture of the right proximal humerus bone. On 10/15/24, the Department issued substantiated findings and a citation of California Code of Regulations, Title 22, Division 6, Chapter 5, Article 6, Section 84078, Subsection (b). The incident and the reason for closing the door were discussed as well as the actions that the licensee has taken to retrain staff and to meet with the Regional Center case manager to confirm staff retraining on C1's care needs. LPM and LPA also discussed the plan of correction developed on 10/15/24 and the licensee's satisfactory completion of the plan of correction. LPMand LPA also discussed the possibility of an assessment of civil penalties due to the nature of the incident and explained the civil penalty process. A copy of this report was provided to with licensee, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On December 13, 2024 (12/13/24) at 11:15AM, Licensing Program Analyst (LPA) Mariah Hawkins met with Administrator and Director Jane Gano at the facility. The purpose of the visit was to meet with Jane to discuss the assessment of an Enhanced Civil Penalty. On 10/15/24, the Department of Social Services, Community Care Licensing Division concluded an investigation into the allegations that a child sustained an unexplained injury while in care and that facility staff did not ensure adequate care and supervision was provided to a child in care. The investigation found that non-ambulatory and non-verbal child C1 (See LIC Confidential Names) sustained an arm fracture during a lapse in supervision. C1's care plan and Regional Center case manager indicated that C1 required one to one (1:1) supervision wherein one staff member provides direct care to solely C1. The investigation found that while the supervising staff member was aware of this requirement, they left C1 unattended for a period of approximately 5 minutes in C1's bedroom with the door closed. During this time, C1 sustained a fracture of the right proximal humerus bone. On 10/15/24, the Department issued substantiated findings and a citation of California Code of Regulations, Title 22, Division 6, Chapter 5, Article 6, Section 84078, Subsection (b). The Department has concluded an analysis of applicable laws and regulations and has determined that an Enhanced Civil Penalty is warranted for a violation resulting in serious bodily injury. Therefore, on this date, pursuant to Health and Safety Code section 1548(f)(1)(C), the Department has issued a civil penalty of $2,500. See attached LIC 421. The above information and appeal rights were discussed during the meeting, and a copy of this LIC 809 report, the LIC 811, the LIC 421, and the licensee's appeal rights were provided to Administrator and Director Jane Gano, whose signature on this form confirms receipt.

met_with: Administrator/Director Jane Gano


summary: Facility Evaluation

raw_content:
Narrative:
On 6/11/25, Licensing Program Analyst (LPA) Mariah Hawkins conducted a required annual inspection. LPA met with Administrator Jane Gano and informed of the purpose of the visit. Using the CARE Inspection Tool, LPA inspected the facility site and grounds and reviewed 5 staff files and 4 client records. LPA observed the facility site and grounds to be maintained in safe condition. There is a large supply of food in the refrigerator, freezers, and cabinets. Bathrooms and kitchen are sanitary. There are three double-occupancy bedrooms, currently sleeping four clients. There are activities and toys available to the clients. LPA observed client records and staff records to be complete. Clients' medications are stored appropriately and medication administration records reflect correct administration. Staff have current first aid and crisis intervention training. All clients in care are nonverbal/non-conversational, so LPA did not conduct any client interviews. LPA did not conduct staff interviews due to time and staff being preoccupied with assigned job duties. LPA conducted observations of all clients and present staff. Staff contact information and schedule were obtained. No deficiency citations were issued at today's inspection. Two areas where technical assistance may be beneficial were noted. See LIC 9102s dated 6/11/25. See also LIC Confidential Names dated 6/11/25. An exit interview was conducted, and a copy of this report, attachments, and licensee's appeal rights were provided to Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On 7/18/25, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit. LPA met with Staff Norman Mabulay and informed of the purpose of the visit. The purpose of the visit was to follow-up on a submitted incident report. Based on staff interviews and review of client records, the facility's program statement, and current public health guidance, it was found that the facility responded to the incident in accordance with facility procedure. LPA identified one area where technical assistance may be beneficial to the licensee. Refer to LIC 9102. No deficiencies were observed, and no citations were issued. An exit interview was conducted, and a copy of this report and the LIC 9102 were provided to Staff Norman Mabulay.


summary: Facility Evaluation

raw_content:
Narrative:
On 9/19/25, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit in order to conduct a health check. LPA met with Facility Manager Mariel Pablo and informed of the purpose of the visit. The purpose for the health check is to follow-up on a reported critical incident at the hospital. LPA gathered additional information and discussed the events leading up to the hospitalization. LPA observed the other clients in care to be in safe condition. No deficiencies were observed during this inspection. An exit interview was conducted, and a copy of this report was left with Facility Manager.


summary: Facility Evaluation

raw_content:
Narrative:
On January 29th 2026, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit to follow-up on a death report received in September 2025. LPA met with Administrator Jane Gano and informed of the purpose of the visit. The report was referred to the licensing agency's investigations branch, who obtained a medical report. Based on the medical report, the investigations branch returned the investigation to LPA Hawkins. Per the medical report, client's immediate cause of death was "undifferentiated shock" with underlying causes of rhinovirus and complications from the client's pre-existing conditions. LPA reviewed client and facility records, including behavior trackers, supervision logs, and medical records. No deficiencies or violations were found that resulted in the client's death. No deficiency citations were issued. An exit interview was conducted, and a copy of this report and the licensee's appeal rights were provided.


summary: Facility Evaluation

raw_content:
Narrative:
On January 29th 2026, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit to follow-up on a record review conducted as part of an investigation at the facility. LPA met with Administrator Jane Gano and informed of the purpose of the visit. Through the investigation, LPA observed an area in which technical assistance may be beneficial to improve recordkeeping. See LIC 9102 attached to today's report. Additionally, LPA requested a copy of the current LIC 500 be emailed to LPA by 5PM Friday, JAN 30th 2026. No deficiency citations were issued. An exit interview was conducted, and a copy of this report and the licensee's appeal rights were provided.


facility_name: KAVERE AT GREEN MOUNTAIN

summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual required inspection was conducted by Licensing Program Analyst (LPA) Tana Kinder on 12/06/2021 at 11: AM. LPA Kinder confirmed prior to the inspection that no staff or clients were experiencing health symptoms related to Covid19. Criminal record clearances were reviewed, and the facility is in compliance. The licensing fees are current. Community Care Licensing file, unusual incident reports, facility roster, facility profile and complaint history were reviewed prior to inspecting the facility. The Group Home is licensed for 4 youth and has 2 youth currently placed. There are 7 staff members currently working at the facility. The facility is in the process of hiring 2 additional staff for Sunday shifts. LPA reviewed 5 staff files. Files reviewed were incomplete. 2 child files were also reviewed. Documentation included emergency contact information, date of placement and personal rights. The charts were complete. The facility was inspected jointly with LPA and Administrator, Rhonda Reid, and the facility is in compliance. A copy of the license, personal rights and emergency exit plan are prominently posted. Client and staff files are in locked cabinets, located in the office. Smoke detectors are in working order, there is a carbon monoxide monitor located in the hallway. A fully charged fire extinguisher is located in the entry and laundry room. There are 4 bedrooms with 1 bed in each bedroom. Each client is provided with a bed, dresser, closet space and a night stand. The 2 bedrooms in use had personal affects. There is 1 bathroom accessible to the clients. There is a hall closet with additional linen if needed for the bedrooms and the bathroom. The kitchen was accessible by the clients. There is a monthly menu posted that is being followed. There was enough perishable/non-perishable food for 2 clients to last 3/8 days. LPA tested the water temperature at multiple faucet locations the reading was between 107.1-110.8 degrees. There is a back patio area, accessible by the youth. The walkway from the front to the back of the facility was clear. The facility vehicle has current insurance and registration. Exit interview conducted and discussed with Rhonda Reid, Administrator, and a copy of the inspection report was provided, including violations and technical violations.

met_with: Program Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst, (LPA) Tana Kinder conducted an unannounced inspection for the purpose of reviewing documentation for the technical violations from the Annual Inspection dated 12/6/2021. LPA reviewed the documentation for staff and client files. The documentation is consistent with CCL regulation requirements. No citations were issued. A copy of this report was provided to the facility.

met_with: DSP Staff


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst, (LPA) Tana Kinder conducted an inspection on 4/26/2022 at 115pm with the Program Director for the purpose of confirming the relocation of the facility. Documentation will be submitted prior to the pre-inspection. All clients (3) have been moved from the current facility to appropriate placements that were coordinated with the Regional Center and their families. There was no evidence of clients living on the premises. All personal belongings and furnishings were removed. No citations were issued. An exit interview was conducted and a copy of this report was provided.

met_with: Program Director


facility_name: KAVERE SERVICES-PINE BROOK HOME

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
All incident reports were documented and sent out properly. Medication logs were audited daily, and all medicine was verified and double checked by another staff member before administering to clients. All staff members have certification to administer medication to clients. Staff client ratios were met and scheduled according to the census of the facility LPA observed medication timers and medication logs filled out on time and signed. Facility has a checks and balances system for administering medication to the clients. No errors were found in medication logs. Staff schedule always had over the client to staff ratio scheduled. LPA found that the allegation was UNSUBSTAINTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. A copy of this report was left with administrator Jai Thompson

Investigation Findings:
13On 11/1/ Licensing Program Analyst (LPA) Rob Sandles met with administrator Jai Thompson at the above facility for the purpose of delivering complaint findings. LPA Sandles requested the following documents: Needs and service plan for all clients in the home, Placement history of facility, Staff trainings for last year, Staff schedule, and Medication Logs LPA interviewed three staff, one administrator, 2 clients in care and a Service Coordinator LPA reviewed requested documents. The allegations are that staff do not provide adequate supervision to the minors while in care, staff are not administering a minor's medication as prescribed, facility has inadequate record keeping and staff did not properly report an incident involving minors while in care. LPA observed through interviews, file review and observation that the medication logs were filled out correctly. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Robert Sandles LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: KAVERE SERVICES-PINE BROOK HOMEFACILITY NUMBER: VISIT DATE: 11/01/2021

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

met_with: Jai Thompson


raw_content:
Narrative:
On 1/12/23, 1/27/23, 2/8/23, 2/17/ IB conducted interviews with three staff, two clients and one prior staff. Confidential interviews revealed inconsistent statements of the incident or how the injury occurred. Based on IB's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No title 22 regulations were cited during today's inspection. Exit interview conducted and a copy of this report was left with Marisa Corral, Administrator.

Investigation Findings:
13Licensing Program Analyst (LPA) Jean Stidman, conducted an unannounced inspection to the facility on 3/24/23 at 1:30pm to deliver complaint allegation findings. LPA met with Marisa Corral, Administrator and discussed the above allegation. During the investigation of Staff hit a child causing injuries to the face, LPA Stephannie Verna toured the facility with Marissa Corral, Administrator on 1/11/23. On this inspection, LPA Verna met with Marissa Corral, Administrator and informed them of the above allegation and that a complaint investigation is in process and will be conducted by CDSS Investigative Branch (IB). On 1/6/23, 1/12/23, 1/17/23, 1/23/ IB investigator Jami Eaton reviewed documentation of Licensing Information System, Field Automated System, Facility personnel report dated 1/11/23, staff schedule for January 2023, client documentation of Individual Program Plan dated 9/22/22, picture of client's bruised lip taken on 1/3/23, client progress notes for 1/1/23 and 1/2/23 and texts from staff to the administrator regarding the incident. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jean Stidman LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: KAVERE SERVICES-PINE BROOK HOMEFACILITY NUMBER: VISIT DATE: 03/24/2023

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

met_with: Marisa Corral, Administrator


raw_content:
Narrative:
unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No title 22 regulations were cited during today's inspection. Exit interview conducted and a copy of this report was left with Marissa Corral, Administrator.

Investigation Findings:
13Licensing Program Analyst (LPA) Jean Stidman, conducted an unannounced inspection to the facility on 6/6/23 at 9:15am to deliver complaint allegation findings. LPA met with Marissa Corral Administrator and discussed the above allegation. During the investigation of facility does not have adequate staffing to supervise youth in care, LPA toured the facility with Marissa Corral Administrator on 1/23/23. On this inspection, LPA obtained documentation for the complaint investigation of current staff's ProAct training, work schedules and client rosters for December 2022 and January 2023. LPA conducted interviews of four staff on 1/23/23, one staff interview on 1/24/23, and the reporting party on 1/26/23. Records reviewed on 1/25/23, 3/13/23 and 5/19/23 revealed the facility had a minimum staff ratio of one staff for four clients during the overnight shift. Then during the day and swing shifts the facility had at minimum one staff for every two clients and at maximum two staff for every client. Interviews revealed that the facility maintains the required staff to child ratio as required by Title 22 regulation 84065.5. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jean Stidman LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: KAVERE SERVICES-PINE BROOK HOMEFACILITY NUMBER: VISIT DATE: 06/06/2023

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

met_with: Marissa Corral Administrator


raw_content:
Narrative:
LPA conducted interviews on 11/20/23, 11/21/23, 2/28/24, and 3/5/24 with the reporting party, four staff and observed the client due to them not being able to participate in an interview. Three out of five confidential interviews reported the client is well groomed and has difficulties allowing the staff to trim their nails due to their diagnosis. Records reviewed showed the client's nails are checked daily and from 6/20/22-8/21/23 the client had marks on their neck on five separate occasions from being self-inflicted. One the day in question, the client had gotten into make-up and it had stained their skin. LPA observed the client to be well groomed and their fingernails did not appear long or uncut. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No title 22 regulations were cited during today's inspection. Exit interview conducted and a copy of this report was left with Marissa Corral Administrator.

Investigation Findings:
13Licensing Program Analyst (LPA) Jean Stidman conducted an unannounced inspection to the facility on 3/7/24 at 4pm to deliver complaint allegation findings. LPA met with Marissa Corral Administrator and discussed the above allegations. During the investigation of minor sustained unexplained marks while in care and staff does not ensure minor's hygiene needs are being met, LPA toured the facility with Marissa Corral Administrator on 11/21/23. On this inspection, LPA inspected the physical plant inside and out, reviewed one client file and obtained documentation for the complaint investigation of Face Sheet, Identification and Emergency Information, admission agreement, needs and services plans for 2022 -2023, physician's reports for 2022 and 2023, behavior intervention plan, individual program plan, quarterly reports for 2023, doctor visit for November 2023, weight record, progress notes-behavior logs for 10/31/23-11/20/23, hygiene tasks for 10/27/23-11/23/23, body check forms for 6/20/22, 6/21/22, 7/18/22, 8/6/23, and 8/21/23, and support team visit rating forms for 12/29/22, 2/15/23, and 11/5/23. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jean Stidman LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: KAVERE SERVICES-PINE BROOK HOMEFACILITY NUMBER: VISIT DATE: 03/07/2024


raw_content:
Narrative:
four children. Seven out of seven interviews with staff AD, S1, S2, S3, S5. S6, and S7 all reported not witnessing or having knowledge of any staff yelling or speaking in appropriately to clients. Interviews with clients C3 & C4 did not report any concerns with not feeling comfortable in the facility. It should be noted that the staff S4 who was alleged in this complaint is on an extended leave and was not interviewed for this complaint and that C1 and C2 are non-verbal and would not participate in an interview. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No title 22 regulations were cited during today's inspection. Exit interview conducted and a copy of this report to provided to Marissa Corral, Administrator.

Investigation Findings:
13Licensing Program Analyst (LPA) Jean Stidman conducted an unannounced inspection to the facility or agency on 12/16/24 at 11am to deliver complaint allegation findings. LPA met with Marissa Corral, Administrator, and discussed the above allegations. During the investigation of staff member yelled at minor, staff member inappropriately spoke to minor, staff member did not provide a comfortable environment for minor, LPAs Sarina Buchannan and Sara Luman-Gonzalez toured the facility with Marissa Corral, Administrator on 8/19/24 and LPAs Jean Stidman and Maie Soliman on 11/6/24 and LPA Stidman on 12/9/24. On these inspections, LPAs inspected the physical plant inside and out and reviewed four client's files. On 8/19/24 and 11/6/ Licensing Program Analyst (LPA) Jean Stidman obtained four children's Needs and Services Plans, staff training logs, client roster and LIC Personnel Report, one child's Identification and Emergency Information, Admission Agreement and case notes for July 2024. LPAs conducted interviews on 11/6/24, 11/21/24 and 12/9/24 with seven staff and UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jean Stidman LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: KAVERE SERVICES-PINE BROOK HOMEFACILITY NUMBER: VISIT DATE: 12/16/2024

met_with: Marissa Corral, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPAs) Jean Stidman and Cecilia Warren made an unannounced (Annual inspection on 4/28/22 at 12:45pm. During the inspection LPAs met with Regina Webb Lead Staff who assisted with the inspection. LPA (analyst name) conducted a walk-through of the facility inside and out. Facility staff-client ratio at time of inspection is 2 staff to 4 clients. Number of staff interviewed Number of clients interviewed LPAs observed # 3 bedrooms, # 3 bathrooms LPAs inspected and/or reviewed the following: I. Physical Plant II. Operations III. Disaster Preparedness IV. Emergency Intervention V. Staffing/Volunteers VI. Client Records VII. Core/Therapeutic Services VIII. Special Health Care Needs (SHCN) An exit interview was conducted and a copy of this report was left with Regina Webb Lead Staff.

met_with: Regina Webb Lead Staff


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
Licensing Program Analyst (LPA) Jean Stidman made an unannounced Annual inspection on 6/2/23 at 9am. During the inspection LPA met with Isaac Herrera, Administrator, who assisted with the inspection. LPA Stidman conducted a walk-through of the facility inside and out. Facility staff-client ratio at time of inspection with two staff and three clients present. One additional client arrived at 1:30pm. Number of staff interviewed _three_ Number of clients interviewed _four_ LPA observed # _three_bedrooms, # _three bathrooms. LPA Stidman inspected and/or reviewed the following: I. Physical Plant Posting of license_X__ Personal Rights__X___ Disinfectants/Cleaning solutions inaccessible__X___ Refrigerator Temperature at or below 45 degrees F __X___ Freezer Temperature at or below 0 degrees__X___ Nonperishable Foods one week and fresh perishable foods two days minimum__X___ Menu present and posted__X____ Working telephone __X_ Carbon monoxide detectors __X_Smoke Detector _X__ First Aid Kit fully stocked_X__ Common Room available__X__ Dining area (enough seating, furniture good condition, not broke or damaged) __X_ Medication centrally stored, locked/inaccessible _X_ Office (locked and privacy) _X_ Hot Water between 105-120 degree F (Properly labeled if over 125 degree F__116 degrees_ Fire Extinguisher May 2023. Toilets wash basin, bath and shower fixtures in good repair/no leaks/hot water temperature _x Soap and Paper towels __X_ Laundry Facilities(available, work assign dates) __X___ Bedrooms-required linen and furnishings __X___ Motor Vehicle properly maintained , lights, tires, registration/insurance and working seat belts_____ Facility free of vermin _X__ Bedroom (required bedding/furniture, furniture in good repair) __X___ II. Operations Complaint Procedures For Youth Reviewed __X____ Board Minutes Reviewed__X___ III.Disaster Preparedness Disaster and mass casualty plan updated and available__X_ Quarterly Drills conducted and documented__X_____ Disaster preparedness supplies verified __X__ IV.Emergency Intervention Review of manual restraint log __X_ Staff training _X___ V.Staffing/Volunteers Number of Staff files reviewed __three Criminal record clearances verified _three___ First Aid Certificate__X__ Certified Administrators certificate valid and current__X_ VI.Client Records Number of Clients files reviewed _four__Needs and Services Plan _four_ Centrally Stored Medication and log reviewed __four_ Psychotropic Medication and log reviewed __X___Cash Resources__X__ The following items were reviewed for compliance: · Annual fees · Administrator Certificate for: Isaac Herrera, Administrator · Emergency Disaster Plan (per H&S Code 1565) · Annual Emergency Intervention Log · Personnel Roster, Facility Sketch, LIC500, LIC610C and LIC308. An exit interview was conducted with Isaac Herrera, Administrator and a copy of this report was left with Isaac Herrera, Administrator.

Deficiencies:
84068.3(a): Modifications to Needs and Services Plan

(a) The needs and services plan specified in Section 84068.2 shall be updated at least every six months to determine the following

met_with: Isaac Herrera, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 3/7/ Licensing Program Analyst (LPA) Jean Stidman met with Marissa Corral Administrator for the purpose of a Case Management Inspection. LPA discussed California Code of Regulation, Title 22, Regulation Administrator Qualifications and Duties. No further investigation is needed. Exit interview conducted and a copy of this report was left with Marissa Corral Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Kayla Green made an unannounced Annual inspection on 7/17/2024 at 10:05am. During the inspection LPA met with Marissa Corral Administrator who assisted with the inspection. LPA Green conducted a walk-through of the facility inside and out. Facility staff-client ratio at time of inspection with two staff and two clients present. Number of staff interviewed _two Number of clients interviewed _two LPA observed # _three_bedrooms, # _three bathrooms. LPA Green inspected and/or reviewed the following: I. Physical Plant Posting of license_X__ Personal Rights__X___ Disinfectants/Cleaning solutions inaccessible__X___ Refrigerator Temperature at or below 45 degrees F __X___ Freezer Temperature at or below 0 degrees__X___ Nonperishable Foods one week and fresh perishable foods two days minimum__X___ Menu present and posted__X____ Working telephone __X_ Carbon monoxide detectors __X_Smoke Detector _X__ First Aid Kit fully stocked_X__ Common Room available__X__ Dining area (enough seating, furniture good condition, not broke or damaged) __X_ Medication centrally stored, locked/inaccessible _X_ Office (locked and privacy) _X_ Hot Water between 105-120 degree F (Properly labeled if over 125 degree F__105.8 degrees_ Fire Extinguisher May 2024. Toilets wash basin, bath and shower fixtures in good repair/no leaks/hot water temperature _x Soap and Paper towels __X_ Laundry Facilities(available, work assign dates) __X___ Bedrooms-required linen and furnishings __X___ Motor Vehicle properly maintained , lights, tires, registration/insurance and working seat belts_____ Facility free of vermin _X__ Bedroom (required bedding/furniture, furniture in good repair) __X___ II. Operations Complaint Procedures For Youth Reviewed __X____ Board Minutes Reviewed__X___ III.Disaster Preparedness Disaster and mass casualty plan updated and available__X_ Quarterly Drills conducted and documented__X_____ Disaster preparedness supplies verified __X__ IV.Emergency Intervention Review of manual restraint log __X_ Staff training _X___ V.Staffing/Volunteers Number of Staff files reviewed __five Criminal record clearances verified _five___ First Aid Certificate__X__ Certified Administrators certificate valid and current__X_ VI.Client Records Number of Clients files reviewed _four__Needs and Services Plan _four_ Centrally Stored Medication and log reviewed __four_ Psychotropic Medication and log reviewed __X___Cash Resources__X__ The facility is being cited a Type B for the modifications of the needs and service plans not having signatures as according to 84068.3 which states "(b)The licensee shall ensure that the child and his/her authorized representative(s) are offered the opportunity to participate in such modifications. (1) The licensee shall not implement any plan modifications unless prior written approval of such modifications has been obtained from the child's authorized representative(s). An exit interview was conducted with Marissa Corral, administrator and a copy of this report was left with Marissa Corral the Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On 11/06/ License Program Analysts (LPAs) Jean Stidman and Maie Soliman met with Marissa Corral, Administrator for the purpose of a case management inspection due to a medication error that occurred on 10/29/2024. LPAs interviewed two staff and reviewed one child's medication records. LPA obtained documentation of the Medication Administration and Inventory Record, Medication Passer and Checker Sign-Off, and Centrally Stored Medication and Destruction Record. Exit interview conducted and a copy of this report to provided to Marissa Corral, Administrator.

met_with: Marissa Corral, AdminIstrator.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/09/ Licensing Program Analyst (LPA) Jean Stidman met with Marissa Corral, Administrator for the purpose of a case management inspection due to a medication error that occurred on 10/29/2024. LPA interviewed one staff. No further investigation is needed. Exit interview conducted and a copy of this report to provided to Marissa Corral, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Jean Stidman made an unannounced Annual inspection on 5/28/25 10:15am During the inspection LPA met with Justin Maae, Administrator, who assisted with the inspection. LPA conducted a walk-through of the facility. There were three children and two staff present during the inspection. Two other staff arrived during the inspection. Number of staff interviewed three Number of clients interviewed one. LPA observed # 4 bedrooms, # 3 bathrooms LPA inspected and/or reviewed the following: Physical Plant Posting of license_X_ Personal Rights__X___ Disinfectants/Cleaning solutions inaccessible__X___ Refrigerator Temperature at or below 45 degrees F 40 degrees Freezer Temperature at or below 0 degrees_0 degrees F Nonperishable Foods one week and fresh perishable foods two days minimum__X___ Menu present and posted__X__ Working telephone __X_ Carbon monoxide detectors __X_Smoke Detector _X__ First Aid Kit fully stocked_X__ Common Room available__X__ Dining area (enough seating, furniture good condition, not broke or damaged) __X_ Medication centrally stored, locked/inaccessible _X_ Office (locked and privacy) _X_ Hot Water between 105-120 degree F (Properly labeled if over 125 degree F__120 degrees_ Fire Extinguishers inspected May 2024. Toilets wash basin, bath and shower fixtures in good repair/no leaks/hot water temperature _x Soap and Paper towels __X_ Laundry Facilities(available) __X___ Bedrooms-required linen and furnishings __X___ Motor Vehicle properly maintained, lights, tires, registration/insurance and working seat belts_X__ Facility free of vermin _X__ Operations Complaint Procedures For Youth Posted _X__ Board Minutes Reviewed __X__ Disaster Preparedness Disaster and mass casualty plan updated and available __X__ Quarterly Drills conducted and documented__x__ Disaster preparedness supplies verified __X___ Emergency Intervention Review of manual restraint log __N/A_ Staff training _X___ Staffing/Volunteers Number of Staff files reviewed _five Criminal record clearances verified _five_ First Aid Certificate_five Certified Administrators certificate valid and current__X_ Client Records Number of Clients files reviewed four Needs and Services Plan four Centrally Stored Medication and log reviewed four Psychotropic Medication and log reviewed three __Cash Resources_four The following items were reviewed for compliance: Annual fees, Administrator Certificate for: Justin Maae, Facility Sketch, LIC500 and LIC610C. An exit interview was conducted, and a copy of this report was left with Justin Maae, Administrator.

met_with: Justin Maae, Administrator


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 6/2/ Licensing Program Analyst (LPA) Jean Stidman met with Isaac Herrera, Administrator for the purpose of a case management inspection. LPA interviewed one staff regarding an incident that the staff witnessed at the facility. The staff failed to report an incident of inappropriate interactions between a staff and a client. The facility is cited per Title 22, Division 6, Chapter 5, Article 06, regulation 84061(a) Reporting Requirements in addition to Section 80061.... An exit interview was conducted with Isaac Herrera, Administrator and a copy of this report was left with Isaac Herrera, Administrator.

Deficiencies:
84061(a): 1
2
3
4
5
6
7

title:
1
2
3
4
5
6
784061(a) Reporting Requirements in addition to Section 80061, the following shall apply..
This requirement is not met as evidenced by

description:
1
2
3
4
5
6
7


facility_name: KAVERE SERVICES-PRINCETON HOME

raw_content:
Investigation Findings:
13Licensing Program Analysts (LPAs) Jean Stidman and Cecilia Warren conducted an unannounced inspection to the facility on 6/14/22 at 11:45am to deliver complaint allegation findings. LPA met with Isaac Herrera, Administrator and discussed the above allegations. During the investigation of staff physically abused minor, staff verbally abused minor, staff threatened minor and staff broke minor's toy. LPA toured the facility with Amanda Gulley Administrator on 4/5/22 and with Shayla Tommila Social Worker on 5/23/22. On these inspections, LPA inspected the physical plant inside and out and no concerns were observed, reviewed one client file, one staff file and obtained documentation for the complaint investigation. LPA conducted interviews on 4/21/22 and 5/12/22. Confidential interviews and documentation reviewed revealed all the allegations are substantiated. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 5, #84072(d)(11), are being cited on the attached LIC 9099D. Exit interview conducted and a copy of this report and a copy of the appeal rights were left at the facility with Isaac Herrera, Administrator. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Cecilia Warren LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: KAVERE SERVICES-PRINCETON HOMEFACILITY NUMBER: 397005954

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


summary: Facility Evaluation

raw_content:
Narrative:
On 2/25/ Licensing Program Analyst (LPA) Jean Stidman met with Amanda Gulley for the purpose of an Annual Inspection. LPA reviewed two client files and four staff files. LPA inspected the facility inside and outside. No deficiencies cited.

met_with: Amanda Gulley Administratot


summary: Facility Evaluation

raw_content:
Narrative:
On 4/5/ Licensing Program Analysts (LPAs) Jean Stidman and Uchenna Ajaero met with Amanda Gulley Administrator for the purpose of investigating an incident that occurred on 3/31/22. LPAs reviewed one client file and one staff file. LPAs received some documentation from these files and requested more documentation from these files be sent via email.

met_with: Amanda Gulley Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Jean Stidman made an unannounced Annual inspection on 2/2/23 at 9:30 am. During the inspection LPA met with Marissa Corral Administrator who assisted with the inspection. LPA conducted a walk-through of the facility inside and out. Facility staff-client ratio at time of inspection 0 staff and 0 clients were present when the inspection began. Number of staff interviewed Number of clients interviewed _0_ LPA observed # 2 bedrooms, # 2 bathrooms LPA Stidman inspected and/or reviewed the following: I. Physical Plant Posting of license_X_ Personal Rights__X_ _ Disinfectants/Cleaning solutions inaccessible__X_ Refrigerator Temperature at or below 45 degrees F _X_ Freezer Temperature at or below 0 degrees_X_ Nonperishable Foods one week and fresh perishable foods two days minimum__X Menu present and posted_X_ Working telephone_X_ Carbon monoxide detectors _X_ Smoke Detector _X_ First Aid Kit fully stocked_X__ Common Room available_X Dining area (enough seating, furniture good condition, not broke or damaged) _X_ Medication centrally stored, locked/inaccessible _X_ Office (locked and privacy) _X_Hot Water between 105-120 degree F (Properly labeled if over 125 degree F_ DEGREES___ Fire Extinguisher (note inspection date) Dec Toilets wash basin, bath and shower fixtures in good repair/no leaks_X_ Soap and Paper towels _X_ Laundry Facilities(available, work assign dates) _X_ Bedrooms-required linen and furnishings _X_ Motor Vehicle properly maintained , lights, tires, registration/insurance and working seat belts_X_ Facility free of vermin _X_ Bedroom (required bedding/furniture, furniture in good repair) _X_ During the inspection LPA observed the hot water temperature was 134 degrees Fahrenheit. LPA observed staff lowered the hot water heater. II. Operations Complaint Procedures For Youth Reviewed X_ Board Minutes Reviewed_X_ III.Disaster Preparedness Disaster and mass casualty plan updated and available_X__ Quarterly Drills conducted and documented___X_ Disaster preparedness supplies verified __X__ IV.Emergency Intervention Review of manual restraint log __X_ Staff training _X_ V.Staffing/Volunteers Number of Staff files reviewed _2_Criminal record clearances verified_X_ First Aid Certificate_X_ Certified Administrators certificate valid and current___x__ Job title/qualification verified __X Hours required training verified__X__ Hours required annual training verified _X__ VI.Client Records Number of Clients files reviewed ___2___Needs and Services Plan _2___ Centrally Stored Medication and log reviewed _2__ Psychotropic Medication Consent forms Reviewed _X_ Psychotropic Medication and log reviewed __x___Cash Resources_x__ VII. Core/Therapeutic Services Trauma Informed Practices are implemented as needed (including specialty mental health services and extracurricular activities and social supports) _X VIII. Special Health Care Needs (SHCN) N/A An exit interview was conducted with Marissa Corral Administrator and a copy of this report was left with Marissa Corral Administrator. Facility citation violation of California Code of Regulations, Title 22, Division 6, regulation 80088(e)(1) Fixtures, Furniture, Equipment and Supplies. During the inspection on 11/15/22 & 12/22/22 the water temperature was 134 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care. The facility turned the hot water temperature down during the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On 2/2/ Licensing Program Analyst (LPA) Jean Stidman met with Marissa Corral Administrator for the purpose of continuing an Annual Inspection, LPA interviewed one client. An exit interview was conducted with Marissa Corral Administrator and a copy of this report was left with Marissa Corral Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Jean Stidman made an unannounced Annual inspection on 9/28/23 at 9:15am. During the inspection LPA met with Isaac Herrera, Administrator, who assisted with the inspection. LPA Stidman conducted a walk-through of the facility inside and out. Facility staff-client ratio at time of inspection with two staff and no clients were present. Two additional staff and two clients arrived during the inspection, Number of staff interviewed _four_ Number of clients interviewed one LPA observed # _two_bedrooms, # _two bathrooms. LPA Stidman inspected and/or reviewed the following: I. Physical Plant Posting of license_X_ Personal Rights__X___ Disinfectants/Cleaning solutions inaccessible__X___ Refrigerator Temperature at or below 45 degrees F 41 degrees Freezer Temperature at or below 0 degrees_-3 degrees F Nonperishable Foods one week and fresh perishable foods two days minimum__X___ Menu present and posted__X____ Working telephone __X_ Carbon monoxide detectors __X_Smoke Detector _X__ First Aid Kit fully stocked_X__ Common Room available__X__ Dining area (enough seating, furniture good condition, not broke or damaged) __X_ Medication centrally stored, locked/inaccessible _X_ Office (locked and privacy) _X_ Hot Water between 105-120 degree F (Properly labeled if over 125 degree F__127.5 degrees_ Fire Extinguishers inspected December 2022. Toilets wash basin, bath and shower fixtures in good repair/no leaks/hot water temperature _x Soap and Paper towels __X_ Laundry Facilities(available) __X___ Bedrooms-required linen and furnishings __X___ Motor Vehicle properly maintained, lights, tires, registration/insurance and working seat belts_X__ Facility free of vermin _X__ Bedroom (required bedding/furniture, furniture in good repair) __X___ II. Operations Complaint Procedures For Youth Reviewed __X____ Board Minutes Reviewed__X___ III.Disaster Preparedness Disaster and mass casualty plan updated and available__X_ Quarterly Drills conducted and documented__X_____ Disaster preparedness supplies verified __X__ IV.Emergency Intervention Review of manual restraint log __X_ Staff training _X___ V.Staffing/Volunteers Number of Staff files reviewed _five Criminal record clearances verified _five_ First Aid Certificate__five__ Certified Administrators certificate valid and current__X_ VI.Client Records Number of Clients files reviewed two Needs and Services Plan two Centrally Stored Medication and log reviewed two Psychotropic Medication and log reviewed __X___Cash Resources__N/A__ Facility citation violation of California Code of Regulations, Title 22, Division 6, regulation 80088(e)(1) Fixtures, Furniture Equipment and Supplies due to the hot water temperature was 127.5 degrees F. LPA observed facility staff turned down the hot water heater during the inspection. The following items were reviewed for compliance: · Annual fees · Administrator Certificate for: Isaac Herrera, Administrator · Emergency Disaster Plan (per H&S Code 1565) · Annual Emergency Intervention Log · Personnel Roster, Facility Sketch, LIC500 and LIC610C. An exit interview was conducted with Isaac Herrera, Administrator and a copy of this report was left with Isaac Herrera, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/7/ Licensing Program Analyst (LPA) Jean Stidman met with Amanda Gulley, Senior Director, for the purpose of conducting a case management inspection. After a review of Kavere Services Pine Brook, Pinetown and Princeton facility's January - July 2023 incident reports for 17 separate medication errors for the Kavere Services Pine Brook, Pinetown and Princeton facilities LPA discovered seven occurred while the clients were on home visits, one occurred while the clients were at school, eight occurred in the facility due to staff errors and one incident occurred at the facility and at school. LPA reviewed the 17 incident reports and the Kavere Medication Policy PowerPoint Slides, three client's medication logs. LPA observed the PowerPoint has 72 slides and observed some slides have information that is duplicated on multiple slides, some information is inconsistent such as the number of Medication Rights varies between five to eight. LPA provided Amanda Gulley, Senior Director, with a list of the 17 incidents and a list of suggested revisions to the PowerPoint slides. Exit interview conducted and a copy of this report was left with Amanda Gulley, Administrator.

met_with: Amanda Gulley, Senior Director


summary: Facility Evaluation

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Narrative:
On 6/13/ Licensing Program Analyst (LPA) Jean Stidman met with Richard Herrera, Executive Administrator, for the purpose of closing this facility. LPA conducted an inspection of the facility and verified there are no children present. The children and the facility files have been moved to Pinetown facility. The original license was surrendered to LPA. No violations were cited. No further investigation is needed. The facility is closed effective 6/13/24. LPA provided a copy of this report to Richard Herrera Executive Administrator on this date.

met_with: Richard Herrera Executive Administrator


facility_name: KAVERE SERVICES - CHERRYLAND HOME

raw_content:
Narrative:
Lastly, LPA Buchannan was unable to gather any further information from the reporting party due to them being anonymous and not having any contact information for them. Although the allegation may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, copy of this report and the Appeal Rights were discussed and provided to the licensee.

Investigation Findings:
13On September 12, 2024 at 12: P.M., Licensing Program Analyst (LPA) Sara Luman-Gonzalez made an unannounced visit to deliver findings to the above Group Home and met with Marissa Corral, Facility Administrator. Prior to the meeting LPA Buchannan conducted the 10-day inspection of the Group Home on 8/19/2024. No deficiencies were cited during that inspection. LPA Buchannan requested the following documents: staff rosters, staff schedule, staff training hours, and client face sheets. LPA Buchannan attempted 1 confidential interview and conducted 7 interviews between 8/19/2024-8/28/2024. Based on evidence obtained and confidential interviews conducted during the investigation process the above allegation cannot be substantiated. 6 out of 7 interviews confirmed that they have never seen, heard, or witnessed any facility staff vaping or smoking on the premises. LPA Buchannan also confirmed during the inspection that there was no designated smoking area at the facility UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Sara Luman-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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: KAVERE SERVICES - CHERRYLAND HOMEFACILITY NUMBER: VISIT DATE: 09/12/2024

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

met_with: Marissa Corral, Facility Administrator


raw_content:
Narrative:
out of 8 interviews confirmed that the staff member accidentally touched the client's stomach while extending their hand to prevent the client from leaving without permission. LPA Buchannan also found that due to the client's trauma history, they can react strongly to any type of touch, perceiving it as harmful. This can lead the client to fabricate stories about the staff who triggered these feelings. Finally, the client stated that the touch was unintentional, explaining that they walked into the staff member's hand, but that they viewed it as a harmful touch. Although the allegation may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, copy of this report and the Appeal Rights were discussed and provided to the licensee

Investigation Findings:
13On November 7, 2024 at 10: AM Licensing Program Analyst (LPA) Sarina Buchannan made an unannounced visit to deliver findings to the above Group Home and met with Facility Administrator, Marissa Corral. Prior to the meeting LPA Sara Luman-Gonzalez conducted the 10-day inspection of the Group Home on 9/18/2024. No deficiencies were cited during that inspection. LPA Luman-Gonzalez requested the following documents: Client Roster, Needs and Service plans, Client Face Sheets, Staff Roster, and Staff File with any disciplinary actions. LPA Buchannan attempted 2 confidential interviews and conducted 8 interviews between 9/18/2024-10/14/2024. Based on evidence obtained and confidential interviews conducted during the investigation process, the above allegation cannot be substantiated. (Continued on LIC 9099C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Sarina Buchannan LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: KAVERE SERVICES - CHERRYLAND HOMEFACILITY NUMBER: VISIT DATE: 11/07/2024

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

met_with: Facility Administrator, Marissa Corral


raw_content:
Narrative:
Based on evidence gathered and confidential interviews conducted during the investigation, the allegations above cannot be substantiated because there were inconsistent statements throughout the investigation process. 7 out of 9 interviews stated that staff do have an appropriate relationship with clients. It was confirmed that in December 2022 an incident occurred in which a staff member took a client to their family gathering. However, it was also verified that this incident took place at a different facility, where the staff member was employed and the client resided at the time, not at the above facility. In addition, LPA was unable to confirm or deny instances of staff taking clients to their home to complete labor, or the client doing any labor while at the family gathering. Also, the investigation was unable to prove or disprove that the facility staff were being discouraged from and not reporting incidents in a timely manner. LPA could not confirm details regarding incidents, or dates of the incidents, which were not being reported. Also, the facility confirmed that there were no formal complaints from staff regarding them being discouraged from reporting and all staff interviewed stated they felt they could report incidents. Lastly, LPA could not determine whether staff mismanaged clients' money and then falsified minors' records. LPA could not establish a time frame in which clients' money was allegedly mismanaged causing staff to falsify the related documentation. Also, a record review did not show any errors in client funds or any missing receipts during the time frame of March 1, 2025, to May 7, 2025. Although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, copy of this report and the Appeal Rights were discussed and provided to the licensee.

Investigation Findings:
13On August 6, 2025 at 12:46PM Licensing Program Analyst (LPA) Tatyana Shulz made an unannounced visit to deliver findings to the above facility and met with Justin Ma'Ae, Adminisrator who granted LPA access to the facility. Prior to the meeting LPA Sarina Buchannan conducted the 10-day inspection of the facility on 05/08/2025. LPA Buchannan requested the following documents: Staff Roster (LIC 500), Client Roster (LIC9020), Staff Schedule (April), Staff Contact Information (April), related incident reports, client needs and services plans, and P&I Records (Last Months). LPA Buchannan conducted 9 and attempted 1 confidential interview between 05/08/2025-07/31/2025. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Tatyana Shulz LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: KAVERE SERVICES - CHERRYLAND HOMEFACILITY NUMBER: VISIT DATE: 08/06/2025

met_with: Justin Ma'Ae-Adminisrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tana Kinder conducted an announced pre licensing inspection with the President, Regional Administrator and Senior Administrator on 2/24/2023 at 10:30 am at the facility. LPA conducted the walk through of the facility with the above named staff and observed 4 bedrooms, 1 garage, 2 common areas, 3 bathrooms, a kitchen, laundry room, staff office and a locked walk-in closet for medication, staff and client files and client funds. All spaces were clean, sanitary, free of insects, and had unobstructed pathways. LPA observed the refrigerator was 31 degrees and the freezer was 0 degrees. The hot water from the kitchen sink was 119.3 degrees. The facility does not utilize protective separation rooms. All the bedrooms are furnished with a bed, dresser, night stand, closet, beanbag chair and are well-lit. One bedroom is set up for 2 clients and the others are for one client. The front yard and back yard are fenced in with an accessible gate to the front of the property. The grounds have a recreation area with a basketball hoop, and a secured swing set that will be set up by April. There is a concrete patio area. There are 2 patio tables in the garage that will be assembled by April to be placed on the patio. There are 4 cameras on the outside of the facility. There are no inside cameras at the facility. The water source is well water that has been analyzed and is safe for consumption. There are 2 fully charged fire extinguishers, one on the first floor, one on the second floor. The smoke detectors and carbon monoxide monitor are linked and in working order. There are locked storage cabinets in the garage. There is a shed in the backyard that is empty. A lock will be put on it. The backyard is fenced off with extra yard on the other side that is not accessible to the clients at this time. On the other side of the locked side yard there are 2 locked workshops that are not in use or accessible to the clients. The facility is using a mini-van to transport clients. There are currently no clients at the facility. Continued... LPA has observed the following that need to be brought into compliance before issuance of the license: Expand facility sketch Post Grievance policy Lock on office closet LPA suggested the following: Move knives from hutch Remove glass from hutch and cabinet doors Remove lock from 3rd cabinet in laundry room LPA reviewed the following forms with the facility staff:

visit_type: Prelicensing

met_with: President


summary: Facility Evaluation

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Narrative:
On August 31, 2023, at 10: AM Licensing Program Analyst (LPA) Shalisa Stiger and Licensing Program Manager (LPM) Rosa Rodriguez conducted an announced Post Licensing visit to the above facility. LPA Stiger called the Administrator and was advised the facility is still waiting on vendor contracts, landscaping completion and currently does not have any clients. The facility hopes to be open in approximately two (2) weeks and will check in with LPA Stiger on any updates. The Administrator will contact LPA Stiger to schedule a follow up Post Licensing Inspection at a later date.

met_with: Richard Herrera, Administrator


summary: Facility Evaluation

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Narrative:
On 04/15/24, Licensing Program Analyst (LPA) Lyta Vue arrived unannounced at the facility and met with Marissa Corral, Program Manager. The purpose of the visit was to conduct a Required Annual Inspection of the facility. This is the first Annual inspection for the facility and a Pre-Licensing was done on 08/31/23. LPA utilized the CARE Tool to complete the Annual inspection. The facility is licensed to provide treatment services for ambulatory children ages six (6) to Seventeen (17) years. The facility currently has (0) clients. Zero (0) client was present during the inspection. The facility is licensed for a maximum capacity of five (5). Staff to client ratio is depended on how many clients. For one (1) client, there will be staff working 168 hours per week and for two (2) clients, there will be staff working 224 hours per week, LPA conducted an inspection of the physical plant and checked for all necessary requirements. The facility had no noticeable odor and maintained an acceptable room temperature. There are a total of four (4) bedrooms available for clients, with one (1) bedroom being a shared bedroom of two (2) clients. The fifth bedroom is used for a locked staff office. LPA observed the client bedrooms, living room, kitchen, three (3) bathrooms, the backyard, the garage, and the staff office to be clean and organized. LPA observed each client bedrooms to have a closet, a dresser, and a clean mattress. Sheets, blankets, and pillows were in good condition. No bedrooms were decorated yet because the facility currently does not have any placement. LPA observed a locked staff office with a locked closet where files and medications will be stored. LPA observed the proper postings including facility license, complaint hotline, menu, and emergency disaster plan. Smoke alarms were in working order, fire extinguishers were current, and a first aid kit was fully stocked. The facility has no outstanding fees. LPA observed some snack items in cabinets but did not observe any food in the kitchen and in the additional refrigerator in the garage because the facility does not have any placement yet. Report continued on 809c Disinfectants and cleaning solutions will be made inaccessible and will be locked in locked cabinets in the garage. There will be extra non-perishable food stored in a pantry in the garage. LPA reviewed zero 0 client files due to the facility not having any placement yet. LPA reviewed zero (0) staff files due to no hired staff yet. LPA interviewed zero (0) staff on site. LPA interviewed zero (0) clients. The facility has no placement and no hired staff. No citations were given on this date. A signed copy of this LIC-809 and LIC 809c report was provided to Marissa Corral, Program Manager.

met_with: Marissa Corral, Program Manager


summary: Facility Evaluation

raw_content:
Narrative:
On August 19, Licensing Program Analysts (LPAs) Sarina Buchannan and Sara Luman-Gonzalez arrive at the Kavere Services Cherryland Home. LPAs were greeted by Marissa Corral who granted LPAs access. LPA's conducted a tour of the inside and outside of the facility where LPA's observed the following deficiencies. Part of the chain link fence in the backyard is sticking out exposing metal. The rear fence gate to the remainder of acreage is unlocked exposing debris and unused building material. Pieces of metal are on the ground along the fence line exposing sharp metal. One bottle of cleaning product was left under the sink without a lock. (See LIC TV) This case management will remain open, until a follow up inspection is conducted to ensure the facility is in full compliance. An exit interview conducted and a copy of this report was left with Marissa Corral.


summary: Facility Evaluation

raw_content:
Narrative:
On August 19, Licensing Program Analysts (LPAs) Sarina Buchannan and Sara Luman-Gonzalez arrived at the Kavere Services Cherryland Home. LPAs were greeted by Marissa Corral who granted LPAs access. LPA's conducted a tour of the inside and outside of the facility where LPA's observed the following deficiencies: · Part of the chain link fence in the backyard is sticking out exposing metal. LPA Buchannan received pictures from the facility on 8/27/24 showing that the part of the chain link that was exposing metal has now been removed and the remainder of the fence is in good repair. On September 12, LPA Luman-Gonzalez observed the broken portion of the chain link fence was removed and is in compliance. · The rear fence gate to the remainder of acreage is unlocked exposing debris and unused building material. LPA Buchannan received pictures from the facility on 8/27/24 showing the fence now has a lock on it and acreage is no longer accessible to clients in care. On September 12, LPA Luman-Gonzalez observed a lock to be on the gate blocking the rear acreage. · Pieces of metal are on the ground along the fence line exposing sharp metal. LPAs Buchannan and Luman-Gonzalez observed the metal be removed while at the facility on August 19, 2024. On September 12, LPA Luman Gonzalez confirmed the metal to be removed and the area is in compliance. · One bottle of cleaning product was left under the sink without a lock. LPA Buchannan received pictures from the facility on 8/27/24 showing the administrator informed staff of the mandatory training and screen shots of staff taking the training via Zoom. On September 12, LPA Luman-Gonzalez observed all cleaning products to be locked up and in compliance. (See LIC TV) This case management that was initially open on August 19, 2024 is now closed. The facility is in full compliance. An exit interview conducted and a copy of this report was left with Marissa Corral.


summary: Facility Evaluation

raw_content:
Narrative:
On March 20, 2025 at approximately 11: AM, Licensing Program Analyst (LPA) Zaria Turner, made an unannounced visit to the above Group Home. LPA Turner met with Facility Administrator, Justin Ma'ae. During the visit, LPA Turner was notified of a recent change in the administration at the facility on March 17, 2025. The department was not notified of the change. According to regulation, Reporting Requirements-84061(e) Effective January 1, 2000, the licensee shall notify the Department, in writing, within ten (10) days of any change in the facility administrator. (f) The licensee shall notify the licensing agency in writing within ten business days of acquiring a new member of the board of directors. The notification shall include the following: (1) Name and residence and mailing addresses of the new administrator. (2) Date he/she assumed his/her position. (3) Description of his/her background and qualifications, including documentation of required education and administrator certification. This case management will remain open until all required documentation needed to formalize the change of administrator has been completed and submitted to the assigned LPA, Sarina Buchannan, via email. An exit interview conducted and a copy of this report was left with Justin Ma'ae, Facility Administrator.

met_with: Justin Ma'ae, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 4/28/2025 at 11: AM Licensing Program Analyst (LPA) Sarina Buchannan made an unannounced visit with the purpose of conducting an annual inspection to the above facility using the Compliance and Regulatory Enforcement (CARE) tool. LPA met with Justin Maae, Facility Administrator and a walk through of the interior and exterior was completed. Physical Plant Room 1 is is a staff office with a copier, bathroom, and closet containing client files and medications and is inaccessible to clients. There is a hallway outside of the office which has 3 locked closets that contain cleaning products and extra toiletries. Room 2 is a living room with 4 couches, TV, and board games. Room 4 is a client bedroom with a twin bed, a dresser, and a night stand. Room 5 is a dining room with a table that seats 6, cotton ball intervention program, and a sliding door leading to the backyard. Room 6 is the kitchen which is connected to the washer dryer area, a client bathroom, and a garage. Room 7 is a client bedroom with a twin bed, 2 dressers, and a night stand. Room 8 is a client bedroom with a twin bed, dresser, and night stand. Room 9 is a loft and has a TV and a desk for activities. Room 10 is a client bedroom with a bed dresser and a night stand. The upstairs hallways has a closet with client toiletries and a bathroom. There are three total bathrooms, one located in the staff office area with a working toilet, and running warm water with a temperature of 115 degrees. There other two bathrooms are client bathrooms with working toilets and running warm water with a temperature of 115 degrees. (report continued on LIC 809C) The backyard is gated with a basketball court, swing set, and a gazebo with a bench. The backyard is clear of debris and clean. The garage has a fooseball table, swing, and a deep freezer. There is a Chrysler Pacifica Hybrid in good working condition, properly maintained, lights, tires, registration/insurance and working seat belts and is available to transport clients if needed. The following required documents were posted, License and Personal Rights. Disinfectants/cleaning solutions inaccessible to children in care. Refrigerator Temperature at or below 45 degrees. Nonperishable foods one week and fresh perishable foods two days minimum. Menu present and posted in the kitchen area on the fridge. Working telephone is available at the facility. Carbon monoxide and smoke detectors are in working order. First Aid Kit fully stocked. Medication centrally stored, locked/inaccessible to children. Hot water between 105-120 degrees Fahrenheit. Fire Extinguisher up to date and in working order. Toilets wash basin, bath, and shower fixtures in good repair/no leaks/hot water temperature. Soap and Paper towels are available to clients. Bedrooms required linen and furnishings are fully stocked. Facility free of vermin. The following domains were also reviewed during today's inspection, Operations, Disaster Preparedness, Staffing, Emergency Intervention, and Client Records. A total of 5 staff files and 4 client files were reviewed. LPA also conducted 3 client interviews, 2 staff interviews, and attempted 1 client interview. A review of the Licensing Information System indicates the facility is up to date on their facility fees. All the staff were fingerprint cleared to the facility. Based on confidential interviews conducted there are no concerns for follow up were noted.

met_with: Justin Maae, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On May 8, 2025, at 2: PM Licensing Program Analyst (LPA) Sarina Buchannan arrived unannounced at the above facility for the purpose of conducting a management inspection. LPA met with Betty Saeyang, Lead Staff, who assisted LPA with the inspection. LPA conducted a walk-through of the facility, and no deficiencies were noted. On April 9, 2025, the facility received an email dated April 6, 2025 with a number of allegations regarding staff and safety of client in care. LPA was informed that the facility was unaware that the information was reportable and therefore did not report to CCL in a timely manner. Facility also stated that the Regional Center had begun an investigation and the original report was addressed to CCL therefore, they believed CCL was already informed. However due to reports not being submitted timely, a technical violation was issued to address the concern. This Case Management is now closed. The facility is being issued a technical violation for Reporting requirements. (see LIC TV). Exit interview conducted and a copy of this report and provided to the Betty Saeyang, Lead Staff.

met_with: Betty Saeyang, Lead


summary: Facility Evaluation

raw_content:
Narrative:
On July 3, 2025 at 2: PM Licensing Program Analyst (LPA) Sarina Buchannan conducted an unannounced inspection to follow up regarding a management. LPA met with Facility Administrator, Justin Ma'ae, who assisted LPA with the inspection. LPA conducted a walk through of the interior and exterior of the facility and no deficiencies were noted. On March 20, LPA Zaria Turner, made an unannounced visit and was notified of a recent change in the administration at the facility. LPA Turner was informed that on March 17, 2025 a new administrator was appointed and the department was not notified of the change. LPA Buchannan requested the facility submit all required documentation within the required time frame in order to appoint the new administrator. On April 11, CCL received all required documentation and officially appointed Justin Ma'ae as this facilities administrator. This case management that was initially opened on March 20, 2025 is now closed. No further investigation needed. Exit interview conducted and a copy of this report was emailed to Justin Ma'ae, Facility Administrator. LPA was unable to print due to technical issues.


summary: Facility Evaluation

raw_content:
Narrative:
On July 3, 2025 at 2: PM Licensing Program Analyst (LPA) Sarina Buchannan made an unannounced case management inspection at the above facility and met with Justin Ma'ae, Facility Administrator, who assisted LPA with the inspection. CCL received an incident report dated May 27, 2025 in which a client was not administered three of their morning medications. LPA requested the following documentation: Medication Log for May 27th, 2025, staff roster with contact information, staff medication training's for staff in question, write ups for staff in question, and a copy of the related incident report. LPA toured the facility and the facility was in full compliance. LPA also conducted 2 staff interviews and 1 client interview. This case management will remain open. Further investigation is needed. Exit interview conducted and a copy of this report was emailed to Justin Ma'ae, Facility Administrator. LPA was unable to print due to technical issues.