summary: Facility Evaluation

raw_content:
Narrative:
On June 13, 2022 at approximately 1: PM, Licensing Program Analysts (LPAs) Juliet Robles and Pamela Silva conducted a visit at the facility for the purposes of initiating a Post Licensing inspection. LPAs met with the representative listed above and discussed the purpose of the visit. The facility currently has a provisional Short Term Residential Therapeutic Program (STRTP) license. The STRTP's Mental Health Program Application is pending approval. The STRTP has pending approval from CARF accreditation. This STRTP is licensed to serve six (6) male clients 7-17 years of age or Non-Minor Dependents, ambulatory only. A walk-through of the physical plant was conducted at approximately 1: PM. The facility is a single-story home situated in a residential area. After entering the front door, postings, including the License, Emergency Disaster Plan, Personal Rights, Ombudsman, Grievance/Policy (Suggestion box), menus and facility sketch. The living room was observed to be clean, in good repair, and furnished with furniture. There is a kitchen and dining room. All kitchen cabinets and appliances were observed to be in good repair. The facility has a total of 4 bedrooms, 1 is converted into staff's office and 3 bathrooms for client use. All rooms were observed to be clean and furniture was observed to be in good repair. The facility has smoke detectors and carbon monoxide that are in all bedrooms, hallways and working. The hot water in the client bathroom was measured to be 110 degrees (F). The medications were stored and locked in a cabinet in the laundry room. Cleansers/chemicals and sharps knives are locked and stored in a safe in the laundry room. There are two First Aid Kits that are checked and are complete. Emergency exits were free from obstruction. During the inspection, LPA conducted a physical tour (inside and out) and reviewed operational requirements: (physical plant; operations; disaster preparedness; emergency intervention plan, staff files, client files, and core-therapeutic services). LPAs reviewed 5 client files and 3 staff files. LPA interviewed 1 client and 1 staff. On today's inspection, there are two Physical Plant Type B citations: 87087.2(a) and 80087 (a) cited during this inspection. LPA was provided with LIC Board Minute Meetings and staffs schedule/personnel report. An exit interview was conducted, and a signed copy of this report LIC 809D, LIC 811 and Appeal Rights were provided to the Administrator.

met_with: Ashley MacLearn


state: CA

facility_name: BELOVED ONES 5

summary: Facility Evaluation

raw_content:
Narrative:
On 09/15/2022 at 9: AM, Licensing Program Analysts (LPA) Pamela Silva and Carrie Palmer conducted an unannounced Annual Inspection at the facility. LPA met with Ashley MacLearn, Administrator. The facility currently has a provisional Short Term Residential Therapeutic Program (STRTP) license. The STRTP's Mental Health Program Application is pending approval. This STRTP is licensed to serve up to six (6) ambulatory male children ages 7-17 years of age. The facility also provides services to non-minor dependents pursuant to W&I Code 16501.1 (C)(1). There are five (5) ambulatory minors currently in placement. The LPAs requested the following: Personnel Report LIC500, Client Roster, Board of Meeting Minutes, Clients and Staff Files. This facility is a single-story home with three (3) bedrooms, three (3) bathrooms, living room, kitchen, dining room, and a staff office. There are no bodies of water on the premises. There are no firearms or ammunition in the facility. At 9: AM, LPAs conducted a walk-through of the entire facility. Physical Plant The license, facility sketch, Personal Rights, Emergency Disaster form, Complaints poster, Foster Youth Bill of Rights, Complaints/Grievance policy, emergency phone numbers and menus are posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions and sharps are kept inaccessible in a locked safe in the laundry room. Facility has non-perishable food for at least one week and perishable food for at least two days. Medications are centrally stored in a locked cabinet in the laundry room. Smoke and carbon monoxide detectors were tested and in proper working order. Fire extinguishers are fully charged. First Aid Kits were checked and found to be complete. Room temperatures are maintained at 76 degrees F. The hot water temperature was tested and measured at 115 degrees F. All sinks, showers and toilets were in working order. No more than 2 children share a bedroom. All beds are in good repair; equipped with good springs, clean mattresses and pillows. Adequate supply of beddings and linens were observed. Facility provides age-appropriate clothing items and hygiene products. Emergency exits are free from obstruction. Overall, facility is clean, safe, sanitary and in good repair. Operations Facility maintains a register of clients and the register is available upon request. The board of directors regularly conduct meetings to review and discuss the STRTP's operation. The facility administrator and manager are the responsible and capable staff for communicating with emergency personnel in the facility. The facility has developed, maintained and implemented written complaint procedures. Core/Therapeutic Services Facility provides core services and supports to children and non-minor dependents as appropriate or necessary that are trauma informed, culturally relevant, age and developmentally appropriate and include the following: Medi-Cal specialty mental health services; transition support services; educational and physical, behavioral, and mental health supports; activities to support children and non-minor dependents and services to achieve permanency. Disaster Preparedness Plan Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts disaster drill at least quarterly for each shift. The drills are documented, and the documentation is maintained in the facility for at least a year. Facility maintains an emergency and disaster plan, register of clients, Needs and Services Plan for each client, medication records, and contact information for each client's responsible party and physician. Client Records LPAs reviewed five (5) client records. All client records are available to the licensing agency to inspect, audit and copy upon demand. Client records contain required information including, but not limited to, consent forms, court orders, needs and services plan, medical assessment; safeguards for cash resources, personal property and valuables; education records; personal rights forms; removal/discipline/complaints form and medication administration records. Staff Records LPAs reviewed three (3) staff records. All staff have been subjected to criminal records review and have been fingerprinted and cleared with DOJ, FBI and CACI. Documentation of the required education and experience requirements are maintained in the personnel file. Documentation of staff training are on file. During records review, LPAs observed that one (1) staff, S3, does not have a Health Screening Form on file. LPAs also observed that S2's file does not show that he meets the qualifications of a facility manager. LPAs interviewed two (2) staff members. Only one (1) client was interviewed due to four (4) clients were in school at the time of inspection. Two (2) Type B citations were issued during today's inspection, see LIC809D. An exit interview was conducted, and a signed copy of this report, LIC809D, LIC811 and appeal rights were provided to the facility administrator.

report_type: Facility Evaluation

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
On 08/03/2022 at 9: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced Annual Inspection at the facility. LPA met with Phillip Cook, Facility Manager. This Short Term Residential Therapeutic Program (STRTP) is licensed to serve up to six (6) ambulatory male children ages 7-17 years of age. The facility also provides services to non-minor dependents pursuant to W&I Code 16501.1 (C)(1). There are five (5) ambulatory minors currently in placement. The LPAs requested the following: Personnel Report LIC500, Client Roster, Board of Meeting Minutes, and Clients and Staff Files. This facility is a single-story home with three (3) bedrooms, three (3) bathrooms, living room, kitchen, dining room, and a staff office. There is an above-ground pool in the backyard which was installed on 06/18/23. There are no firearms or ammunition in the facility. At 9: AM, LPA conducted a walk-through of the entire facility. Physical Plant The license, facility sketch, Personal Rights, Emergency Disaster form, Complaints poster, Foster Youth Bill of Rights, Complaints/Grievance policy, emergency phone numbers and menus are posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions and sharps are kept inaccessible in a locked safe in the laundry room. Facility has non-perishable food for at least one week and perishable food for at least two days. Medications are centrally stored in a locked cabinet in the laundry room. Smoke and carbon monoxide detectors were tested and in proper working order. Fire extinguishers are fully charged. First Aid Kits were checked and found to be complete. Room temperatures are maintained at 76 degrees F. The hot water temperature was tested and measured at 110 degrees F. All sinks, showers and toilets were in working order. No more than 2 children share a bedroom. All beds are in good repair, equipped with clean mattresses and pillows. Adequate supply of beddings and linens were observed. Facility provides age-appropriate clothing items and hygiene products. Emergency exits are free from obstruction. Above-ground pool has a cover, and the ladder is removed and made inaccessible when not in use. Overall, facility is clean, safe, sanitary and in good repair. Operations Facility maintains a register of clients and the register is available upon request. The board of directors regularly conduct meetings to review and discuss the STRTP's operation. The facility administrator and manager are the responsible and capable staff for communicating with emergency personnel in the facility. The facility has developed, maintained and implemented written complaint procedures. Core/Therapeutic Services Facility provides core services and supports to children and non-minor dependents as appropriate or necessary that are trauma informed, culturally relevant, age and developmentally appropriate and include the following: Medi-Cal specialty mental health services; transition support services; educational and physical, behavioral, and mental health supports; activities to support children and non-minor dependents and services to achieve permanency. Disaster Preparedness Plan Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts disaster drill at least quarterly for each shift. The drills are documented, and the documentation is maintained in the facility for at least a year. Facility maintains an emergency and disaster plan, register of clients, Needs and Services Plan for each client, medication records, and contact information for each client's responsible party and physician. Client Records LPA reviewed five (5) client records. All client records are available to the licensing agency to inspect, audit and copy upon demand. Client records contain required information including, but not limited to, consent forms, court orders, needs and services plan, medical assessment; safeguards for cash resources, personal property and valuables; education records; personal rights forms; removal/discipline/complaints form and medication administration records. Staff Records LPA reviewed three (3) staff records. All staff have been subjected to criminal records review and have been fingerprinted and cleared with DOJ, FBI and CACI. Documentation of the required education and experience requirements are maintained in the personnel file. Documentation of staff training are on file. LPA interviewed two (2) staff members. Two (2) clients were interviewed. Three (3) clients refused to be interviewed. No deficiency citations are being issued at this time. An exit interview was conducted, and a signed copy of this report was provided to the facility administrator.

met_with: Phillip Cook


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Pamela Silva and Juliet Robles on 08/15/24 at 12: PM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Corie Thomas, Interim Administrator, and inspected the facility inside and out. LPAs reviewed one (1) of child's records and three (3) of staff personnel files on site at the facility. LPAs reviewed one (1) of child's psychotropic medications and medication records. LPAs interviewed two (2) of staff on site to discuss the facility's policies and procedures of operation. LPAs interviewed one (1) child currently prescribed psychotropic medication. No deficiencies are being cited at this time. LPAs conducted exit interview and provided a copy of this report to the Interim Administrator, Corie Thomas.

visit_type: Case Management

met_with: Corie Thomas


summary: Facility Evaluation

raw_content:
Narrative:
On Monday June 2, 2025, at 12:45PM, Licensing Program Analyst (LPA) Humberto Flores, conducted a Case Management inspection at Beloved Ones Short Term Residential Therapeutic Program (STRTP) and met with Willy Ayala, Supervisor Facility Manager (SFM). The purpose of the inspection was to conduct a criminal record review of all staff working at the facility. LPA Flores obtained a copy of the LIC Personnel Report and conducted a search and review in Guardian. The information revealed that all seventeen (17) employees listed in the LIC500 dated 05/05/2025, have a criminal record clearance from the Department of Justice (DOJ), Federal Bureau of Investigation (FBI) and Child Abuse Central Index (CACI), prior to the staff's employment. No further inspection is needed. No citation was issued. A copy of this report was provided, via email, to the STRTP representative. Exit interview conducted.

met_with: Supervisor Facility Manager, Willy Ayala


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Juliet Robles and Pamela Silva on 07/29/25 at 12: PM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Robles met with Iesha Johnson, Facility Manager and inspected the facility inside and out. LPAs reviewed 0 of child's records and 3 of staff personnel files on site at the facility. There are no children currently that take psychotropic medications. LPA interviewed 1 of staff on site to discuss the facilities policies and procedures of operation. LPA provided a copy of this licensing report to Iesha Johnson, Facility Manager. No deficiencies are being cited at this time. A Technical Advisory was issued (see LIC 9102). LPA conducted an exit interview with Iesha Johnson, Facility Manager.

met_with: Iesha Johnson


summary: Facility Evaluation

raw_content:
Narrative:
On July 29, 2025 at 9: AM, Licensing Program Analysts (LPAs) Pamela Silva and Juliet Robles conducted an unannounced Annual Random inspection at the facility. LPAs met with Iesha Johnson, Facility Manager. This STRTP is licensed to serve up to two (2) ambulatory children ages 7-17 years of age. The facility also provides services to non-minor dependents pursuant to W&I Code 16501.1 (C)(1). There is one (1) minor currently in placement. The LPAs requested the following: Personnel Report LIC500, Client Roster, Board of Meeting Minutes, Client and Staff Files. This facility is a single-story home with two (2) bedrooms, three (3) bathrooms, living room, kitchen, dining room, a staff office and a mental health office. There is a portable above-ground pool in the backyard which is being re-installed during summer. There are no firearms or ammunition in the facility. At 10: AM, LPAs conducted a walk-through of the entire facility. Physical Plant The license, facility sketch, Personal Rights, Emergency Disaster form, Complaints poster, Foster Youth Bill of Rights, Complaints/Grievance policy, emergency phone numbers and menus are posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions and sharps are kept inaccessible in a locked safe in the garage. Facility has non-perishable food for at least one week and perishable food for at least two days. Medications are centrally stored in a locked cabinet inside the office. Smoke and carbon monoxide detectors are in proper working order. Fire extinguishers are fully charged. First Aid Kits were checked and found to be complete. Room temperatures are maintained at 75 degrees F. The hot water temperature was tested and measured at 120 degrees F. All sinks, showers and toilets were in working order. No more than 2 children share a bedroom. Adequate supply of beddings and linens were observed. Facility provides age-appropriate clothing items and hygiene products. Emergency exits are free from obstruction. Above-ground pool has a cover, and the ladder is removed and made inaccessible when not in use. Overall, facility is clean, safe, sanitary and in good repair. Operations Facility maintains a register of clients and the register is available upon request. The board of directors regularly conduct meetings to review and discuss the STRTP's operation. The facility administrator and manager are the responsible and capable staff for communicating with emergency personnel in the facility. The facility has developed, maintained and implemented written complaint procedures. Core/Therapeutic Services Facility provides core services and supports to children and non-minor dependents as appropriate or necessary that are trauma informed, culturally relevant, age and developmentally appropriate and include the following: Medi-Cal specialty mental health services; transition support services; educational and physical, behavioral, and mental health supports; activities to support children and non-minor dependents and services to achieve permanency. Disaster Preparedness Plan Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts disaster drills once a month. The drills are documented, and the documentation is maintained in the facility for at least a year. Facility maintains an emergency and disaster plan, register of clients, Needs and Services Plan for each client, medication records, and contact information for each client's responsible party and physician. Client Records LPA reviewed one (1) client records. Client records are available to the licensing agency to inspect, audit and copy upon demand. Client records contain required information including, but not limited to, consent forms, court orders, needs and services plan, medical assessment; safeguards for cash resources, personal property and valuables; education records; personal rights forms; removal/discipline/complaints form and medication administration records. Staff Records LPA reviewed three (3) staff records. All staff have been subjected to criminal records review and have been fingerprinted and cleared with DOJ, FBI and CACI. Documentation of the required education and experience requirements are maintained in the personnel file. Documentation of staff training are on file. LPA interviewed one (1) client and one (1) staff member. No deficiency citations are being issued at this time. A Technical Advisory was issued, see LIC9102TA. An exit interview was conducted, and a signed copy of this report was provided to the Facility Manager.


summary: Facility Evaluation

raw_content:
Narrative:
On 09/10/25 at 9: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced case management inspection at the above facility and met with Facility Manager, Iesha Johnson. The purpose of the inspection is to follow up on a Law Enforcement Contact Report LIC621LE received by the Department on 07/31/25. The LIC624LE indicated that client C1 took multiple pills and had possession of a pumpkin cutter. LPA Silva conducted telephone interviews with five (5) staff on 07/31/25, 08/04/25 and 08/05/25. Interviews revealed that on July 24, 2025, after the PM shift change, C1 was being aggressive to staff S2, shoved S2 three times and threatened to attack S2. S2 stepped out of the facility and stayed outside to avoid escalation with C1 while calling for staff support. During this time, S2 was the only staff covering the shift as another staff was running late. While S2 was outside waiting for staff support, C1 allegedly broke into the locked garage and got a hold of a screwdriver and a pumpkin cutter from the toolbox. Then, C1 broke into the locked office using the screwdriver and took the locked medication destruction box to his room. S2 did not see what was going on inside the facility as he was outside. C1 was the only client placed at the facility at the time of the incident. C1 was inside the office holding a screwdriver when three (3) staff members arrived at the facility to provide support. Staff was able to de-escalate C1 and had C1 turn over the screwdriver. Staff members were not aware that C1 had already taken the pumpkin cutter and medication destruction box inside his room before they arrived. Staff S2 left the facility to avoid triggering C1 and another staff covered the shift. Later at about MN, law enforcement and paramedics were called to respond due to C1 throwing up after taking multiple pills and having possession of a pumpkin cutter. LPA reviewed the incident report for possible late reporting. The incident happened on 07/24/25 and the written report was received on 07/31/25. However, it was determined that an incident notification was emailed to the Department on 07/25/25. Based on the information gathered from interviews and records reviewed, three (3) deficiency citations are being cited during today's inspection, see LIC809D. Plan of corrections were discussed with the Facility Manager, Iesha Johnson. An exit interview was conducted, and a copy of this report and the appeals rights were provided to the Facility Manager, Iesha Johnson.


summary: Facility Evaluation

raw_content:
Narrative:
On 09/14/23 at 10: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced case management inspection at the above facility and met with Director, Thandi Smith. The purpose of the inspection is to follow up on a referral from the county received by the Department on 08/30/23. The referral was regarding 2 clients who were observed to be doing inappropriate behavior (refer to Confidential Names List LIC811 dated 09/14/23). LPA interviewed the Assistant Administrator and the facility's therapist. Staff, S1, who observed the behavior immediately redirected the two (2) clients to come out of the room to watch movies with the staff. Clients denied the inappropriate behavior and stated that they were just wrestling. The two clients do not share a room and were closely monitored by staff after the incident by conducting their room checks. Staff also referred the incident to the therapist. Based on LPA interview with therapist, the clients denied the inappropriate behavior and explained that they were just wrestling over the game controller. The therapist explained to clients the importance of acting appropriately. Based on LPA review of Unusual Incident Reports (UIRs), the incident was not reported to the Department. The facility was in violation of Title 22, Division 6, Chapter 1, Article Reporting Requirements 80061(b)(1)(E). A Type B deficiency citation is being issued during today's inspection, see LIC809D. An exit interview was conducted. A copy of this report along with appeal rights were provided to the facility representative.

met_with: Thandi Smith


summary: Facility Evaluation

raw_content:
Narrative:
On 03/07/24 at 11: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced case management inspection at the above facility and met with Supervising Facility Manager (SFM), Corie Thomas. The purpose of the inspection is to follow up on an Unusual Incident Report (UIR) received by the Department on 01/30/24. The UIR indicated that on 01/29/24, client C1 (refer to Confidential Names List LIC811 dated 03/07/24) scraped his left heel on the metal screen door while coming out of the office. C1's heel bled, and staff applied first aid on the wound. The UIR also stated that the work order is in place to get the metal screen door fixed or replaced. On 02/07/24, LPA Silva contacted SFM Corie Thomas via telephone call to follow-up on the status of the broken metal screen door. Based on a photo of the door requested to be sent to LPA Silva on 02/07/24, the metal door has not been fixed and is still in use with sharp edges protruding at the bottom of the door. LPA Silva requested for a copy of the work order and observed that the order was from 11/13/23, which means that the door has been in disrepair since November 2023. This is in violation of Title Division Chapter Article 6, 80087(a) on Building and Grounds. A deficiency citation is being issued, see LIC809D. Plans of correction were discussed with the Supervising Facility Manager. An exit interview was conducted. A copy of this report, LIC809D, LIC 811 and appeal rights were provided to the facility representative.


facility_name: BELOVED ONES SIX

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
It was alleged that one staff member at the facility made inappropriate comments towards multiple clients in care. The alleged comments ranged from derogatory remarks to general disrespect. In interviews conducted, one child stated that the staff member did indeed use derogatory remarks towards clients in care and was verbally abusive in general. However, three other children stated that they had not seen or heard of the staff member ever making inappropriate comments, or verbally abusing any clients in care. Two children stated that the staff member was more strict than others but would remain professional in dealing with the clients. All children interviewed revealed that they felt safe in the home and could count on staff members to help them with anything that they needed. In interviews conducted, four staff members denied the allegation and stated that they have not seen or heard of any staff members in the facility making inappropriate statements to clients in care. Staff reiterated that even though clients may be challenging and frustrating at times, they are trained to be gentle and understanding towards clients in care. A review of records revealed no indications that staff have ever been verbally abusive towards clients in care. Based on interviews conducted and records reviewed, there is not a preponderance of evidence to prove that the above allegation occurred. Although the allegation may have happened or may be valid, there were no outside witnesses to confirm whether the incidents were improperly supervised and if they could have been prevented. Therefore, the allegation is deemed UNSUBSTANTIATED. An exit interview was conducted and a signed copy of this report, along with the Licensee's Appeal Rights (LIC 9058 01/16) was provided to the Licensee.

Investigation Findings:
13On April 27, 2022 at approximately 12: PM, Licensing Program Analyst (LPA) Raymond Wu conducted a follow-up complaint inspection with the facility to deliver the findings of a complaint investigation concerning the allegation above. LPA discussed the finding with the facility representative named above. During the course of the investigation, LPA interviewed clients and staff on 02/03/22 and 03/31/22. LPA also reviewed documents on 04/24/22 including, but not limited to, needs and services plan(s), and incident reports. One child at the center of this investigation was unable to be interviewed due to reunification with birth family. Attempts to contact the birth family were unsuccessful. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Raymond Wu 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELOVED ONES SIXFACILITY NUMBER: VISIT DATE: 04/27/2022

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

report_type: Complaint Investigation

met_with: Supervising Facility Manager Tiffany Cotledge

complaint_status: unsubstantiated


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Information obtained through confidential statements and a character witness (W1) statement it was revealed that S3 did in fact verbally abuse a client (C1) by calling C1 "a fat lazy bitch" which is a Personal Rights violation. This is a violation of the Short-Term Residential Therapeutic Program Interim Licensing Standards regulation 87072 (11) "To be free of physical, sexual, emotional, or other abuse, and from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature including, but not limited to, interference with the daily living functions of eating, sleeping, or toileting, or withholding of shelter, clothing, or aids to physical functioning." If not corrected, it will have a direct and immediate risk to the health and safety of the children in care. Therefore, the above allegation is substantiated. The agency was cited, and a plan of correction was initiated. Appeal rights were provided and discussed with the STRTP Administrator. A copy of the report and the Confidential Name List (LIC811) dated October 7, 2022, was provided to the STRTP Administrator, and an exit interview was conducted.

Investigation Findings:
13On October 7, 2022 at 11: AM, Licensing Program Analyst (LPA) Winston Moroney, conducted a follow-up complaint inspection to the above Short-Term Residential Therapeutic Program (STRTP) and met with STRTP Administrator Ashley MacLearn. The purpose of the inspection was to deliver a finding for the above complaint allegation. It was alleged that staff member S3 verbally abused minor C1 while in care. The investigation of the above allegation was conducted by LPA Moroney, which consisted of, but was not limited to, a review of records including the client's needs and services plans, interviews with two staff members (S1, S2) on 9/1/2022, TS on 9/12/22, five clients (C1, C2, C3, C4, C5) on 9/1/22, San Bernardino County Social Services Practitioner (SSP) on 9/1/22 and a witness (W1) on 9/9/22. (No statement was obtained from the alleged perpetrator due to not returning phone calls). (Reference Confidential Names Form LIC 811, dated October 7, 2022). SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Winston Moroney 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 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELOVED ONES 6FACILITY NUMBER: VISIT DATE: 10/07/2022

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

met_with: Ashley MacLearn - Administrator

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Substantiated - 3 allegations

raw_content:
Narrative:
Page The Department received a referral regarding alleged conduct inimical by a facility staff. The referral reported staff (S1) allegedly raped a former client, who is now an adult (A1). S1 denied the allegation. However, S1 confirmed A1 spent the night at his home and slept on his bed on 9/12/23. The investigation revealed S1 did not follow the facility's polices and procedures by fraternizing with A1 while she was placed in the facility via text message using his personal cellular phone. Statements obtained from interviews conducted with facility staff consistently indicated staff are trained to not engage in behavior that may be deemed inappropriate, such as giving clients their personal cellular phone number. Per interviews conducted with staff, staff are reminded of the policy during bi-weekly meetings. Based on S1 admitting he was inappropriate by providing his contact information to A1 while she was a client at the facility and maintained contact with her by calling, texting, and seeing her outside of the facility, all of which was against the facility policy, which he confirmed he was aware of as evidenced by his signed acknowledgement, the allegation is Substantiated. The facility is cited for violation of Interim Licensing Standards, Short Term Residential Therapeutic Program Article 6, standard 87072(c)(15) Personal Rights. S1 violated A1's personal rights by failing to maintain a formal staff/client relationship by fraternizing with A1 while she was a youth placed at the facility. A copy of this report, LIC809D, LIC811 were given to the above mentioned facility representative. Appeals rights were provided. Per the new Civil Penalty laws, Health and Safety (H&S) Code section 1548(E), an Enhanced Civil Penalty (ECP) determination is pending due to the substantiated allegation. If an ECP is warranted, a Community Care Licensing (CCL) representative will return to the facility to deliver the penalty assessment.

Investigation Findings:
13An unannounced follow up complaint inspection was conducted by Licensing Program Analyst (LPA) Christopher Larios on 11/16/23 at 9: AM. During the inspection LPA Larios met with Supervisor Jerrell Jackson. The purpose of the inspection was to deliver findings for the above-mentioned complaint allegation. The investigation was conducted by Community Care Licensing Division (CCLD) Investigations Branch (IB) State Investigator (SI) Romelia Munoz. During the course of the investigation LPA Larios conducted a record review on 9/21/23 and obtained copies of, but not limited to, staff roster and contact information, staff training records, job description, staff evaluations and client roster, needs and services plans and special incident reports. SI Munoz then conducted interviews with one law enforcement officer, two facility managers, a client and an administrator between 9/20/23 and 10/25/23. SI Munoz conducted a record review and obtained copies of a social worker's delivered service log, Kern County Sheriff's report and a signed acknowledgement of the facility policies from a staff's file. Continued on page SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Christopher Larios 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELOVED ONES 6FACILITY NUMBER: VISIT DATE: 11/16/2023

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 0

met_with: Jerrell Jackson


raw_content:
Narrative:
Allegation - Staff do not prevent a minor from threatening another minor. One client stated that the clients were just playing when they threatened to kill each other. Ref. #2 denied threatening anyone. Based upon the interview with the Administrator Fletcher, the clients engaged in regular children's behavior. The Administrator stated that the staff tried to keep Ref. #1 and #2 separated. The LPA received inconsistent information regarding the allegation. Allegation - Staff do not prevent a minor from having access to marijuana. Interviews with the Administrator Fletcher revealed that Ref. #2 smoked in the bedroom at the facility. The Administrator revealed that initially the facility did not have approval to search Ref. #2 when Ref. #2 returned from outside activities, but received approval from the County Social Worker. Once the approval was received Ref. #2 was searched for contraband. The Administrator stated that the situation was referred to mental health services. There was no preponderance of the evidence to substantiate the allegations. So, although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the allegations are unsubstantiated. There are no deficiencies to be cited regarding these allegations. A copy of this complaint was provided to the facility representative.

Investigation Findings:
13On December 7, 2023 at 2:45 p.m., Licensing Program Analyst (LPA), Karen McGee, delivered the findings of a complaint investigation. The LPA met with Administrator, Tiffany Cotledge. On August 2, 2023, the Monterey Park Children's Residential Program (MPCRP), received a complaint with the above mentioned allegations. Confidential interviews were conducted that included, but were not limited to: Administrator Jeanne Fletcher and two clients, Ref. #1 and #2, at the facility on August 3, 2023; one County Social Worker via telephone on December 5, 2023. After a few attempts the LPA did not receive a call back from the CSW for Ref. #1. The LPA reviewed the Needs & Services Plans and incident reports. Allegation - Staff did not prevent a minor from kicking another minor. The interviews did not reveal evidence that one client kicked the other. The staff did not witness one client kick the other. An interview with the Administrator Fletcher indicated that it was not reported to the staff, so there is no incident report regarding one client kicking the other. There were not witnesses to this allegation. This allegation was not corroborated. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Karen McGee 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 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELOVED ONES 6FACILITY NUMBER: VISIT DATE: 12/07/2023

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

met_with: Tiffany Cotledge


raw_content:
Narrative:
Based upon the inspection and interviews, the complaint findings are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the allegations occurred. A copy of this report was given to the above representative. No deficiencies were cited.

Investigation Findings:
13On July 1st, 2025, at 12: PM, Licensing Program Analyst (LPA) Ashley Ruacho completed the investigation on the above allegations. While investigating the allegations LPA conducted an inspection to the Short-Term Residential Therapeutic Program (STRTP). LPA toured the facility with the Administrator (AD) and observed that all smoke detectors were installed and in working order on 06/18/25. When speaking with AD the smoke detectors were not removed from the facility but taken down to change the battery and put back up by staff the same day. LPA also observed that one lock on a client bedroom door was reversed and on the outside of the bedroom. AD stated that a previous client had a history of AWOL and stated the door had the lock on the outside to ensure safety of the client and was not for the purpose of locking the client inside the bedroom. Client is no longer at the facility; LPA requested the facility to place the lock back on the proper side. During the visit the AD placed the lock to its original side, inside the bedroom. (See Confidential Names LIC 811 dated July 1st, 2025). Due to the inconsistency of information obtained during the investigation, it cannot be determined whether the above allegations occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Ashley Ruacho 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 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELOVED ONES 6FACILITY NUMBER: VISIT DATE: 07/01/2025

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

met_with: TIFFANY COTLEDGE - ADMINISTRATOR


raw_content:
Narrative:
LPA conducted an investigation into the aforementioned allegations. This investigation included, but was not limited to, a thorough review of various records, such as the client's needs and service plans, medical records, SIR's and the police report. Additionally, interviews were conducted with three staff members: S1 on 3/6/25, S2 on 3/12/25, and S3 on 4/17/25. Furthermore, two out of four clients were interviewed: C3 on 4/17/25 and C4 on 3/12/25. An interview was also held with one San Bernardino County Social Worker (CSW3) on 4/23/25. It is important to note that no statements were obtained from C1 or C2, as they chose not to provide one. (Reference Confidential Names Form LIC 811, dated June 19, 2025). [The following allegations were reported.] 1. The staff did not provide adequate supervision, resulting in minor AWOLing and engaging in drug use. The staff members (S1, S2, S3) denied the allegations, asserting that the safety of their clients is their utmost priority and that they would never compromise their safety. The staff noted that the facility has between one to three staff members present, depending on the facility's requirements, while adhering to the Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards, which stipulate a staff-to-client ratio of 1:4. Additionally, on the day of the alleged incident, February 24, 2025, staff received a call from the school requesting the pickup of clients C1 and C2 due to their cutting class and being caught using a wax pen behind the school. Upon their return from school, C1 and C2 expressed a desire to play basketball in the backyard under the supervision of S3. S3 reported that C1 and C2 hit the ball over the backyard fence and permitted C1 to retrieve it; however, both clients jumped the fence and began to walk away from the STRTP. S3 promptly followed them in the company vehicle and attempted to verbally redirect them to return to the vehicle and go back to the STRTP, but these efforts were unsuccessful. S3 stated that they pursued the clients until they lost sight of them as they ran through fields, neighboring backyards, and crossed a pedestrian bridge. S3 informed S1 that they had lost sight of the clients and quickly contacted local law enforcement to file a missing person's report for both clients. Continued.... S1 and S3 reported that the clients eventually returned to the STRTP on their own, declined any medical attention, and underwent a visual inspection for contraband, which yielded no findings on either C1 or C2. S1 then reached out to law enforcement to notify them of the clients' return to the STRTP. Later that day, a peace officer visited the STRTP to check on and speak with C1 and C2 before leaving shortly thereafter. 2. The staff did not report minors' elopement in a timely manner. The Staff (S1, S2, and S3) refuted the allegation, asserting that all incidents are reported without delay to all relevant agencies. S1 additionally noted that the incident that took place on February 24, 2025, involving C1 and C2 going AWOL was not reported immediately because S3 had visual contact with C1 and C2. Once S3 lost sight of C1 and C2, S1 instructed S3 to search the familiar areas where clients typically go AWOL; however, S3 was unable to find the clients, leading to a missing person's report being submitted to the local law enforcement. S1 emphasized that once a staff member loses sight of said client, staff will adhere to protocol and the Needs and Services of the respective client. S1 mentioned that staff will allow thirty minutes for the client to return before alerting local Law Enforcement. Furthermore, confidential statements acquired from clients C3 and C4 contradicted the allegations, affirming that the facility staff is consistently present and that clients are regularly monitored by the staff. C3 and C4 expressed that they felt secure living at the facility and appreciated the involvement of the facility staff with the clients. Information gathered from CSW3 indicated that they have no issues concerning the care and supervision provided to their clients and that staff would always promptly notify them of any incidents through email or text. Therefore, based on the information received, the above allegation(s) are determined to be unsubstantiated. Although the allegation(s) may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred, therefore, the allegation(s) are found to be unsubstantiated. Appeal Rights were provided and discussed with the STRTP Administrator. There are no deficiencies to be cited at this time. An exit interview was conducted, and a copy of the report along with the (LIC 811) was left with the STRTP Administrator.

Investigation Findings:
13On July 24, 2025, at 10: AM, Licensing Program Analyst (LPA) Winston Moroney carried out an unannounced inspection of the aforementioned Short-Term Residential Therapeutic Program (STRTP) to present the findings related to the stated complaint. LPA engaged with the Administrator of the STRTP and reviewed the results concerning the identified allegation(s). On February 27, 2025, the California Department of Social Services Community Care Licensing Division received a complaint from Centralized Complaint and Information Bureau (CCIB) with the following allegation(s): The staff did not provide adequate supervision, resulting in minor AWOLing and engaging in drug use; the staff did not report minors elopement in a timely manner. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Winston Moroney 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELOVED ONES 6FACILITY NUMBER: VISIT DATE: 07/24/2025

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

met_with: Tiffany Cotledge - STRTP Administrator


raw_content:
Narrative:
cont.# The information revealed that the staff at this STRTP take most of their training in an online database, while other training is taken in person. The topics of training include, but are not limited to, crisis intervention, emergency procedures, trauma informed care, and regulatory compliance. At the time of the file review the Administrator did not have a current cardiopulmonary resuscitation and first aid certificate. LPA Flores, having considered the evidence provided during the investigation, deemed the allegation substantiated. A citation was issued on LIC809 dated 5/09/2025 for violation of Interim Licensing Standards (ILS), Version 5: Section 87065.1 (b)(8)(A): (A) Completion of cardiopulmonary resuscitation (CPR) and first aid training shall be demonstrated by current and valid CPR and first aid cards issued by the American Red Cross, the American Heart Association, a training program approved by the State Emergency Medical Services Authority pursuant to Health and Safety Code Section 1797.191, or from an accredited college or university. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. No further inspection is needed. A copy of this report, appeal rights and LIC811 was provided to the facility representative. Exit interview conducted.

Investigation Findings:
13On Thursday October 2, 2025, at 12:45PM, Licensing Program Analyst (LPA) Humberto Flores, conducted a follow-up complaint inspection at Beloved Ones Short Term Therapeutic Program (STRTP) and met with Administrator, Tiffany Cotledge. The purpose of the inspection was to deliver the findings for the above complaint allegation. The initial information that generated this complaint investigation stated that staff have not completed the training required at the facility. Reporting Party (RP) states the training is to ensure staff are equipped to handle resident care, crisis intervention, emergency procedures, trauma informed care, and regulatory compliance. RP states that despite multiple email notifications sent to staff, no action has been taken to complete the training from Relias. LPA Flores investigated the allegation and conducted interviews with RP, Administrator, and Executive Director (ED). A review of the Administrator and one Facility Manager Ref (FM) training records was reviewed, and copies were made available. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Humberto Flores 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 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELOVED ONES 6FACILITY NUMBER: VISIT DATE: 10/02/2025

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

met_with: Administrator, Tiffany Cotledge


summary: Facility Evaluation

raw_content:
Narrative:
On 5/27/21 at 5:30pm, Licensing Program Analyst (LPA) Johanna Lofton made an announced telephone call inspection at Fir Avenue, CA 93505. This facility is located in a residential area. The video call took place with the purpose of conducting a pre-licensing inspection for Beloved Ones 6. The telephone inspection was shown by the Jessica Hatley, Facility Administrator. This facility will be licensed for six (6) male clients. The inspection started at the facility's entrance. LPA Lofton saw and confirmed it was the correct address in a residential neighborhood. This facility is a one story home which consist of six (6) bedrooms, three (3) bathrooms, living room, dining room, kitchen, garage, front yard and backyard. The entrance of the facility will be equipped with thermometer, sanitizer, gloves and forms to check in client, staff and visitors for a Covid-19 symptoms triage. The facility had all utilities turned on and in working order. Smoke and Carbon Monoxide detectors were tested and found to be in working order. LPA observed a fire extinguisher located in the kitchen. Bedrooms #`1, #2, and #3 will be used for clients. Bedrooms #4, #5 and #6 will be use as therapy room, video/game room and office. Clients will have access to two bathrooms. The third bathroom will be for the staff use. Medicine and cleaning supplies will be locked in the hallway closet. There will be no sharp knives or utensils at the facility. All food will be pre-cut. There were no weapons or bodies of water on the premises. The facility is equipped with security sensor alarm for the security of the clients. Facility furniture and appliances were to be moved to the facility on 6/06/21. LPA Lofton will conduct a post- licensing visit for further inspection. Exit interview was conducted and a copy of this report was sent to Facility Director Thandi Smith for review and signature due to Covid-19 restrictions.

visit_type: Prelicensing

met_with: Jessica Hatley- Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 05/05/2022 at 8: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced Post Licensing Inspection at the facility. LPA met with Jessica Hatley, Administrator. The facility currently has a provisional Short Term Residential Therapeutic Program (STRTP) license. The STRTP's Mental Health Program Application is pending approval. This STRTP is licensed to serve up to six (6) ambulatory male children ages 7-17 years of age. The facility also provides services to non-minor dependents pursuant to W&I Code 16501.1 (C)(1). There are four (4) ambulatory minors currently in placement. The LPAs requested the following: Personnel Report LIC500, Client Roster, Board of Meeting Minutes, Clients and Staff Files. This facility is a one-story home with three (3) bedrooms, three (3) bathrooms, living room, game room, kitchen, dining room, staff office, front yard and backyard. There are no bodies of water on the premises. There are no firearms or ammunitions in the facility. At 8: AM, LPA conducted a walkthrough of the entire facility. Physical Plant The license, facility sketch, personal rights, emergency disaster form, complaints poster, emergency phone numbers and food menu are posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions and sharps are kept inaccessible in a locked closet. Facility has non-perishable food for at least one week and perishable food for at least two days. Medications are centrally stored in a locked storage room. Smoke and carbon monoxide detectors were tested and in proper working order. Fire extinguishers were fully charged. First Aid Kits were checked and found to be complete. Room temperatures are maintained at 76 degrees F. The hot water temperature was tested and measured at 117 degrees F. All sinks, showers and toilets were in working order. No more than 2 children share a bedroom. All beds are in good repair; equipped with good springs, clean mattresses and pillows. Adequate supply of beddings and linens were observed. Facility provides age-appropriate clothing items and hygiene products. Overall, facility is clean, safe, sanitary and in good repair. Operations Facility maintains a register of clients and the register is available upon request. The board of directors regularly conduct meetings to review and discuss the STRTP's operation. The facility administrator and manager are the responsible and capable staff for communicating with emergency personnel in the facility. The facility has developed, maintained and implemented written complaint procedures. Core/Therapeutic Services Facility provides core services and supports to children and non-minor dependents as appropriate or necessary that are trauma informed, culturally relevant, age and developmentally appropriate and include the following: Medi-Cal specialty mental health services; transition support services; educational and physical, behavioral, and mental health supports; activities to support children and non-minor dependents and services to achieve permanency. Disaster Preparedness Plan Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts disaster drill at least quarterly for each shift. The drills are documented, and the documentation is maintained in the facility for at least a year. Facility maintains an emergency and disaster plan, register of clients, Needs and Services Plan for each client, medication records, and contact information for each client's responsible party and physician. Client Records LPA reviewed four (4) client records. All client records are available to the licensing agency to inspect, audit and copy upon demand. Client records contain required information including, but not limited to, consent forms, court orders, needs and services plan, medical assessment; safeguards for cash resources, personal property and valuables; education records; personal rights forms; removal/discipline/complaints form and medication administration records. During records review, LPA observed that Cash Resources Logs for all four (4) clients did not contain February through current month's information. LPA also observed that one (1) client's psychotropic medication did not match the Psychotropic Medication Administration Record (PMAR). Staff Records LPA reviewed two (2) staff records. All staff have been subjected to criminal records review and have been fingerprinted and cleared with DOJ, FBI and CACI. Documentation of the required education and experience requirements are maintained in the personnel file. Documentation of staff training are on file. LPA interviewed two (2) staff members. No client was interviewed due to all four (4) clients being in school at the time of inspection. At the conclusion of the inspection, LPA discussed the findings with the facility administrator. LPA issued two (2) Type B deficiency citations, see LIC809D. LPA agreed to work with the facility administrator to collaborate with guidance to get the facility in compliance with ILS and Title 22 regulations. An exit interview was conducted, and a signed copy of this report, LIC811, LIC809D and appeal rights were provided to the facility administrator.

met_with: Jessica Hatley


summary: Facility Evaluation

raw_content:
Narrative:
On 06/13/2022 at 8: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced Annual Inspection at the facility. LPA met with Thandi Smith, Administrator. The facility currently has a provisional Short Term Residential Therapeutic Program (STRTP) license. The STRTP's Mental Health Program Application is pending approval. This STRTP is licensed to serve up to six (6) ambulatory male children ages 7-17 years of age. The facility also provides services to non-minor dependents pursuant to W&I Code 16501.1 (C)(1). There are five (5) ambulatory minors currently in placement. The LPAs requested the following: Personnel Report LIC500, Client Roster, Board of Meeting Minutes, Clients and Staff Files. This facility is a one-story home with three (3) bedrooms, three (3) bathrooms, living room, game room, kitchen, dining room, staff office, front yard and backyard. There are no bodies of water on the premises. There are no firearms or ammunition in the facility. At 9: AM, LPA conducted a walk-through of the entire facility. Physical Plant The license, facility sketch, personal rights, emergency disaster form, complaints poster, emergency phone numbers and food menu are posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions and sharps are kept inaccessible in a locked closet. Facility has non-perishable food for at least one week and perishable food for at least two days. Medications are centrally stored in a locked storage room. Smoke and carbon monoxide detectors were tested and in proper working order. Fire extinguishers were fully charged. First Aid Kits were checked and found to be complete. Room temperatures are maintained at 76 degrees F. The hot water temperature was tested and measured at 118 degrees F. All sinks, showers and toilets were in working order. No more than 2 children share a bedroom. All beds are in good repair; equipped with good springs, clean mattresses and pillows. Adequate supply of beddings and linens were observed. Facility provides age-appropriate clothing items and hygiene products. Overall, facility is clean, safe, sanitary and in good repair. Operations Facility maintains a register of clients and the register is available upon request. The board of directors regularly conduct meetings to review and discuss the STRTP's operation. The facility administrator and manager are the responsible and capable staff for communicating with emergency personnel in the facility. The facility has developed, maintained and implemented written complaint procedures. Core/Therapeutic Services Facility provides core services and supports to children and non-minor dependents as appropriate or necessary that are trauma informed, culturally relevant, age and developmentally appropriate and include the following: Medi-Cal specialty mental health services; transition support services; educational and physical, behavioral, and mental health supports; activities to support children and non-minor dependents and services to achieve permanency. Disaster Preparedness Plan Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts disaster drill at least quarterly for each shift. The drills are documented, and the documentation is maintained in the facility for at least a year. Facility maintains an emergency and disaster plan, register of clients, Needs and Services Plan for each client, medication records, and contact information for each client's responsible party and physician. Client Records LPA reviewed five (5) client records. All client records are available to the licensing agency to inspect, audit and copy upon demand. Client records contain required information including, but not limited to, consent forms, court orders, needs and services plan, medical assessment; safeguards for cash resources, personal property and valuables; education records; personal rights forms; removal/discipline/complaints form and medication administration records. Staff Records LPA reviewed two (2) staff records. All staff have been subjected to criminal records review and have been fingerprinted and cleared with DOJ, FBI and CACI. Documentation of the required education and experience requirements are maintained in the personnel file. Documentation of staff training are on file. LPA interviewed two (2) staff members. Two (2) clients were interviewed and the other three (3) clients refused to be interviewed. No deficiency citations were issued during today's inspection. An exit interview was conducted, and a signed copy of this report and LIC811 were provided to the facility administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On 05/03/2023 at 9: AM, Licensing Program Analysts (LPAs) Pamela Silva and Juliet Robles conducted an unannounced Annual Inspection at the facility. LPAs met with Thandi Smith, Administrator. The facility currently has a provisional Short Term Residential Therapeutic Program (STRTP) license. The STRTP's Mental Health Program Application is pending approval. This STRTP is licensed to serve up to six (6) ambulatory children ages 7-17 years of age. The facility also provides services to non-minor dependents pursuant to W&I Code 16501.1 (C)(1). There is one (1) minor and one (1) non-minor dependent currently in placement. The LPAs requested the following: Personnel Report LIC500, Client Roster, Board of Meeting Minutes, Clients and Staff Files. This facility is a one-story home with three (3) bedrooms, three (3) bathrooms, living room, game room, kitchen, dining room, staff office, front yard and backyard. There are no bodies of water on the premises. There are no firearms or ammunition in the facility. At 10: AM, LPAs conducted a walk-through of the entire facility. Physical Plant The license, facility sketch, personal rights, emergency disaster form, complaints poster, emergency phone numbers and food menu are posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions and sharps are kept inaccessible in a locked closet. Facility has non-perishable food for at least one week and perishable food for at least two days. Medications are centrally stored in a locked storage room. Smoke and carbon monoxide detectors were tested and in proper working order. Fire extinguishers were fully charged. First Aid Kits were checked and found to be complete. Room temperatures are maintained at 76 degrees F. The hot water temperature was tested and measured at 106 degrees F. All sinks, showers and toilets were in working order. No more than 2 children share a bedroom. All beds are in good repair; equipped with good springs, clean mattresses and pillows. Adequate supply of beddings and linens were observed. Facility provides age-appropriate clothing items and hygiene products. Overall, facility is clean, safe, sanitary and in good repair. Operations Facility maintains a register of clients and the register is available upon request. The board of directors regularly conduct meetings to review and discuss the STRTP's operation. The facility administrator and manager are the responsible and capable staff for communicating with emergency personnel in the facility. The facility has developed, maintained and implemented written complaint procedures. Core/Therapeutic Services Facility provides core services and supports to children and non-minor dependents as appropriate or necessary that are trauma informed, culturally relevant, age and developmentally appropriate and include the following: Medi-Cal specialty mental health services; transition support services; educational and physical, behavioral, and mental health supports; activities to support children and non-minor dependents and services to achieve permanency. Disaster Preparedness Plan Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts disaster drill at least quarterly for each shift. The drills are documented, and the documentation is maintained in the facility for at least a year. Facility maintains an emergency and disaster plan, register of clients, Needs and Services Plan for each client, medication records, and contact information for each client's responsible party and physician. Client Records LPAs reviewed two (2) client records. All client records are available to the licensing agency to inspect, audit and copy upon demand. Client records contain required information including, but not limited to, consent forms, court orders, needs and services plan, medical assessment; safeguards for cash resources, personal property and valuables; education records; personal rights forms; removal/discipline/complaints form and medication administration records. Staff Records LPAs reviewed five (5) staff records. All staff have been subjected to criminal records review and have been fingerprinted and cleared with DOJ, FBI and CACI. Documentation of the required education and experience requirements are maintained in the personnel file. Documentation of staff training are on file. During records review, one (1) out of five (5) staff did not have a TB screening on file. LPAs interviewed two (2) clients and two (2) staff members. One (1) deficiency citation was issued during today's inspection, see LIC809D. An exit interview was conducted, and a signed copy of this report and LIC811 were provided to the facility administrator.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Pamela Silva on August 03, 2023 at 11: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Silva met with Jeanne Fletcher, Supervising Facility Manager, and inspected the facility inside and out. LPA reviewed one (1) of child's records and two (2) of staff personnel files on site at the facility. LPA reviewed one (1) of child's psychotropic medications and medication records. LPA interviewed two (2) of staff on site to discuss the facility's policies and procedures of operation. LPA interviewed one (1) child currently prescribed psychotropic medications. No deficiencies are being cited at this time. LPA provided a copy of this licensing report and conducted exit interview with Jeanne Fletcher, Supervising Facility Manager.

met_with: Jeanne Fletcher


summary: Facility Evaluation

raw_content:
Narrative:
On 9/28/23 at 10: AM, Licensing Program Analyst (LPA) Christopher Larios conducted an unannounced case management inspection at the Short Term Residential Therapeutic Program (STRTP) and met with Director Thandi Smith. The purpose of the inspection was to follow up on the facility buildings and grounds. On 9/12/23 the Department received a law enforcement contact report dated 9/10/23. The report stated that a vehicle drove through the facility backyard fence, damaging the fence and a pool. On 9/21/23, LPA Larios conducted an unannounced inspection at the facility and observed the backyard fence in disrepair. Pieces of wood from the fence were observed on the floor and a gap in the fence was uncovered, permitting access to the facility. The facility informed LPA Larios that they were not permitted to fix the fence due to an ongoing law enforcement investigation. On 9/28/23, LPA Larios visited the law enforcement agency who responded to the incident and was informed a report was unavailable due to the ongoing investigation. Law enforcement stated the responding officers should not have advised the facility to leave the fence in disrepair and in addition, informed LPA Larios the facility can repair the fence. On 9/28/23, LPA Larios conducted a follow up visit to the facility and observed the fence has since been repaired and in good condition. Due to the repair of the fence no further follow-up is required. Exit interview conducted. A copy of this report was given to the above-mentioned facility representative. No deficiencies were cited.


summary: Facility Evaluation

raw_content:
Narrative:
On 10/19/23 at 12: PM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced case management inspection at the above facility and met with the Facility Manager, Jerrell Jackson. The purpose of the inspection is to follow up on an Unusual Incident Report (UIR) received by the Department on 09/28/23 regarding client C1 missing his medication for several days (refer to Confidential Names List LIC811 dated 10/19/23). Based on an interview with staff S1, one of C1's medication was discontinued per physician's order. C1's doctor ordered a medication change for C1 after re-assessment. C1 missed about 5 days of the new medication awaiting prescription from doctor. LPA Silva reviewed email communication between C1's doctor and the facility regarding the change in medication. A new medication authorization for C1 indicating discontinuance and replacement of medication for C1 was on file and was also reviewed by LPA. Due to the confirmation of an authorization for a medication change, no further follow-up is needed. No deficiency citation is being issued during today's inspection. An exit interview was conducted. A copy of this report was provided to the facility representative.


summary: Facility Evaluation

raw_content:
Narrative:
On 10/19/23 at 12: PM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced case management inspection at the above facility and met with the Facility Manager, Jerrell Jackson. The purpose of the inspection is to follow up on a Law Enforcement Contact Report LIC624LE received by the Department on 10/03/23. The incident indicated that client C1 inflicted self-harm by cutting herself on the forearm with a piece of glass from a perfume bottle (refer to Confidential Names List LIC811 dated 10/19/23). Based on an interview with the facility's Director, C1 broke a small perfume bottle from her room and used it to cut her forearm. The facility manager confirmed that there are no sharps or knives in the facility that are accessible to clients. Upon seeing C1 bleeding from her forearm, staff S1 immediately called law enforcement and Emergency Medical Team (EMT) to seek medical assistance. S1 also monitored C1 to make sure she did not continue to hurt herself while waiting for the EMT. Once EMT arrived, C1 was given first aid to stop the bleeding and was later taken to the hospital. C1's county social worker (CSW) stated during a telephone interview on 10/16/23 that she has not seen any negligence on the part of the facility regarding the incident. CSW has no safety concerns regarding the facility. Based on the information gathered, no further follow-up is needed. No deficiency citation is being issued during today's inspection. An exit interview was conducted. A copy of this report was provided to the facility representative.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Timika Martin 08/15/24 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA met with Administrator, Tiffany Cotledge and inspected the facility inside and out. LPA reviewed two (2) of child's records and three (3) of staff personnel files on site at the facility. LPA reviewed two (2) of child's psychotropic medications and medication records. LPA interviewed two (2) of staff on site to discuss the facility's policies and procedures of operation. LPA will conduct interviews at a later date due to no clients being available during the time of inspection. No deficiencies are being cited at this time. LPA conducted exit interview with Tiffany Cotledge, Administrator and provided a copy of this licensing report.

met_with: Tiffany Cotledge, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 10/02/24 at 10: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced case management inspection at the above facility and met with Interim Administrator, Tiffany Cottledge. The purpose of the inspection is to follow up on a Special Incident Report (SIR) received by the Department on 09/24/24. The incident indicated that staff S1 grabbed client C1 by the neck in an attempt to have C1 get up to clean up the mess C1 made in the kitchen (refer to Confidential Names List LIC811 dated 10/02/24). During the inspection, LPA Silva requested for the following documents to review: LIC Personnel Report, Client Roster, LIC Personnel Record for S1 and Training Records for S1. Further follow-up is needed to complete this case management. No deficiency citation is being issued during today's inspection. An exit interview was conducted, and a copy of this report was provided to Ms. Cottledge.

met_with: Tiffany Cottledge


summary: Facility Evaluation

raw_content:
Narrative:
On 03/12/25 at 12: PM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced case management inspection at the above facility and met with Administrator, Tiffany Cotledge (S1). The purpose of the inspection is to follow up on a Special Incident Report (SIR) received by the Department on 12/23/24. The incident indicated that staff S2 held client C1's arms to prevent C1 from running away (refer to Confidential Names List LIC811 dated 03/12/25). LPA Silva reviewed the SIR and restraint log. LPA also conducted a telephone interview with S1 via telephone on 01/13/25. Records review and interview revealed that on 12/21/24, staff S2 blocked client C1 by standing in front of the door to prevent C1 from running away. Additionally, S2 grabbed C1's arms from behind to turn C1 around and away from the door during a runaway attempt. S2 then released C1's arms and C1 left the facility. Per S1, S2 confirmed that the incident occurred. On 01/03/25, S1 had a discussion with S2 regarding proper restraint protocol. S2 was given a verbal warning. A review of S2's record showed training on emergency intervention and proper restraint. Based on the information gathered from confidential interviews and records reviewed, a Technical Violation on STRTP Interim Licensing Standards, Emergency Intervention Prohibitions 87095.01( c)(7) is being issued (see LIC9102TV). An exit interview was conducted and a copy of this report was provided to Ms. Cotledge.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Juliet Robles and Pamela Silva on 05/21/25 at 9: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Robles met with Tiffany Cotledge, Administrator and inspected the facility inside and out. LPAs reviewed 0 of child's records and 3 of staff personnel files on site at the facility. LPAs reviewed 0 of child's psychotropic medications and medication records. LPAs interviewed 0 of child's currently prescribed psychotropic medication. LPAs interviewed 2 of staffs on site to discuss the facilities policies and procedures of operation. LPAs provided a copy of this licensing report to Tiffany Cotledge, Administrator. No deficiencies are being cited at this time. A Technical Advisory was issued (see LIC9102TA). LPAs conducted exit interview with Tiffany Cotledge, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On 05/19/2025 at 9: AM, Licensing Program Analysts (LPAs) Pamela Silva and Juliet Robles conducted an unannounced Annual Inspection at the facility. LPAs met with Tiffany Cotledge, Administrator. This STRTP is licensed to serve up to six (6) ambulatory children ages 7-17 years of age. The facility also provides services to non-minor dependents pursuant to W&I Code 16501.1 (C)(1). There are two (2) minors currently in placement. The LPAs requested the following: Personnel Report LIC500, Client Roster, Board of Meeting Minutes, Clients and Staff Files. This facility is a one-story home with three (3) bedrooms, three (3) bathrooms, living room, game room, kitchen, dining room, staff office, front yard and backyard. There are no bodies of water on the premises. There are no firearms or ammunition in the facility. At 9: AM, LPA conducted a walk-through of the entire facility. Physical Plant The license, facility sketch, personal rights, emergency disaster form, complaints poster, emergency phone numbers and food menu are posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions and sharps are kept inaccessible in a locked closet. Facility has non-perishable food for at least one week and perishable food for at least two days. Medications are centrally stored in a locked storage room inside the office. Smoke and carbon monoxide detectors were tested and in proper working order. Fire extinguishers were fully charged. First Aid Kits were complete. Room temperature is maintained at 65 degrees F. The hot water temperature was tested and measured at 109 degrees F. All sinks, showers and toilets were in working order. No more than 2 children share a bedroom. All beds are in good repair; equipped with good springs, clean mattresses and pillows. Adequate supply of beddings and linens were observed. Emergency exits are free from obstruction. Overall, the facility is clean, safe, sanitary and in good repair. Operations Facility maintains a register of clients and the register is available upon request. The board of directors regularly conduct meetings to review and discuss the STRTP's operation. The facility administrator and manager are the responsible and capable staff for communicating with emergency personnel in the facility. The facility has developed, maintained and implemented written complaint procedures. Emergency Intervention Documentation of emergency intervention training for staff is on file. The facility maintains a monthly restraint log which will be submitted bi-annually to the Department. Core/Therapeutic Services Facility provides core services and supports to children and non-minor dependents as appropriate or necessary that are trauma informed, culturally relevant, age and developmentally appropriate and include the following: Medi-Cal specialty mental health services; transition support services; educational and physical, behavioral, and mental health supports; activities to support children and non-minor dependents and services to achieve permanency. Disaster Preparedness Plan Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts disaster drill at least quarterly for each shift. The drills are documented, and the documentation is maintained in the facility for at least a year. Facility maintains an emergency and disaster plan, register of clients, Needs and Services Plan for each client, medication records, and contact information for each client's responsible party and physician. Client Records LPAs reviewed two (2) client records. All client records are available to the licensing agency to inspect, audit and copy upon demand. Client records contain required information including, but not limited to, consent forms, court orders, needs and services plan, medical assessment; safeguards for cash resources, personal property and valuables; education records; personal rights forms; removal/discipline/complaints form and medication administration records. Staff Records LPAs reviewed three (3) staff records. All staff have been subjected to criminal records review and have been fingerprinted and cleared with DOJ, FBI and CACI. Documentation of the required education and experience requirements are maintained in the personnel file. Documentation of staff training are on file. During records review, one (1) out of three (3) staff members did not meet education and experience qualifications. LPAs interviewed one (1) client and two (2) staff members. One (1) deficiency citation was issued during today's inspection, see LIC809D. Technical Advisories were issued, see LIC9102TA. An exit interview was conducted, and a signed copy of this report and appeals rights were provided to the facility administrator.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Rachel Vanegas made an announced visit at the above facility for the purpose of interviewing Client #1 regarding an incident that occurred at a different facility. LPA conducted an exit interview with Iesha Johnson, Supervising Facility Manager. A copy of this report, LIC 811, and appeal rights were reviewed and provided to Iesha Johnson, Supervising Facility Manager. A signed copy of this report was provided to the regional office and is located in the facility file.

met_with: Supervising Facility Manager - Iesha Johnson


summary: Facility Evaluation

raw_content:
Narrative:
On Friday May 09, 2025, at 11:45AM, Licensing Program Analyst (LPA) Humberto Flores, conducted a Case Management Inspection at Beloved Ones Short Term Therapeutic Program (STRTP) and met with Supervisor Facility Manager Tiffany Cotledge. The purpose of the inspection is to address the below deficiencies observed during the inspection. A file review inspection was conducted for employees Ref #1 (S1), Ref #2 (S2), Ref #3 and Ref #4 (S4) (see Confidential Names form LIC811 dated 05/09/2025). During the inspection LPA Flores observed that S1, S2 and S3 were not associated to the STRTP prior working at the facility. An immediate assessment of civil penalties of one hundred dollars ($100) per violation for a maximum of 5 days was assessed, for a total of $1500 (one thousand and 5 hundred dollars). The civil penalties were assessed from 05/05/2025 to 05/09/2025. Date of hire (DOH) is inputted in the LIC811. This is a violation of California Code of Regulations (CCR), Title 22, Division 6, Section 80019 (e)(3): Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or cont.# During this inspection it was observed that S4 did not have a current Cardiopulmonary Resuscitation (CPR) and First Aid Training Certificate. This is a violation of the below regulations: - Interim Licensing Standards (ILS), Version 5, Section 87065.1 (b)(8)(A) (8) Facility manager training is in addition to first aid and CPR training, and other training as required in Section 87095.65. (A) Completion of cardiopulmonary resuscitation (CPR) and first aid training shall be demonstrated by current and valid CPR and first aid cards issued by the American Red Cross, the American Heart Association, a training program approved by the State Emergency Medical Services Authority pursuant to Health and Safety Code Section 1797.191, or from an accredited college or university. Two (2) citations type A were issued. These are violations of the regulations and the Health and Safety Code that, if not corrected, have a direct and immediate risk to the health, safety or personal rights of those in care. A copy of this report, citation page, appeal rights, and LIC811 was provided, via email, to the STRTP representative. Exit interview conducted.


summary: Facility Evaluation

raw_content:
Narrative:
On April 13, 2022 at 11: AM, Licensing Program Analyst (LPA) Juliet Robles conducted an unannounced case management inspection to Beloved Ones Six, a Short Term Therapeutic Residential Treatment (STRTP) facility and met Ashley Mac Learn, Admnistrator. The special incident report (SIR) disclosed that on 03/06/22, client (C1) (reference Confidential Names Form LIC 811 dated 04/13/22) got into verbal argument with Staff (S2) leading to C1 spitting at S2's face and C1 getting slapped by S2. Per Administrator, on the day that the incident happened, he had three staffs assigned to the facility that called in sick. S1 and S2 normally works on the other Beloved Ones facility. Per Administrator, it was time for the hygiene, bedtime routine and that C1 does not want to turn in his tablet to comply. S1 informed S2 that C1 still has a tablet in his hand, S2 went to C1 to collect the tablet. At this time, C1 is upset and spit at S2's face which in return S2 slapped C1 in the face being witnessed by S1. Per S2, he did not touch C1 and when he got spat in the face, he just walked away. During the investigation, LPA did confidential telephone interviews with the administrator on 03/29/22, S1 & S2 on 04/07/22 and an in person visit today 04/13/22 with C1. Based on the information obtained through interviews and records review, a deficiency citation is issued under Interim Licensing Standards (ILS) 87072(c)(11) Personal Rights. (c)The licensee shall ensure that each child, regardless of whether the child is in foster care, is accorded the personal rights specified in Welfare and Institutions Code Section 16001.9, as applicable. In addition, the licensee shall ensure that each child is accorded the following personal rights: (11)To be free of physical, sexual, emotional, or other abuse, and from corporal or unusual punishment, *exploitation,* infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature including, but not limited to, interference with the daily living functions of eating, sleeping, or toileting, or withholding of shelter, clothing, or aids to physical functioning. The following reports were provided to the facility representative: LIC 809, LIC 809-d, LIC Confidential Names and Appeal Rights forms.

met_with: Ashley Mac Learn


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 09/14/23 at 9: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced case management inspection at the above facility and met with the Director, Thandi Smith. The purpose of the inspection is to follow up on an Unusual Incident Report (UIR) received by the Department on 08/20/23. The incident indicated that staff S1 gave client C1 the wrong medication at the wrong time (refer to Confidential Names List LIC811 dated 09/14/23). A review of the UIR indicated that S1 admitted to giving C1 the wrong medication at the wrong time. During inspection, LPA reviewed S1's medication administration training and C1's Psychotropic Medication Administration Records (PMARs). Based on interviews with staff, it was determined that the Facility Manager (S2) was not on site at the exact time of the incident. Staff explained that S2 had to step out of the facility to transport another client. The facility was in violation of the Health & Safety Code HSC 1507.6(b)(1) and Interim Licensing Standards (ILS) Personnel Requirements 87097.65(g). Two (2) Type B deficiency citations are being issued during today's inspection, see LIC809D. An exit interview was conducted. A copy of this report along with appeal rights were provided to the facility representative.

Deficiencies:
87097.65(g): 1
2
3
4
5
6
7

title:
1
2
3
4
5
6
7Personnel Requirements.  The licensee shall designate at least one facility manager to be present at the facility at all times when one or more children are present.

This requirement is not met as evidenced by

description:
1
2
3
4
5
6
7


summary: Facility Evaluation

raw_content:
Narrative:
On 10/11/24 at 11: AM, Licensing Program Analysts (LPA) Pamela Silva and Juliet Robles conducted an unannounced case management inspection at the above facility and met with Interim Administrator, Tiffany Cotledge (S1). The purpose of the inspection is to follow up on a Special Incident Report (SIR) received by the Department on 09/24/24. The incident indicated that staff S1 grabbed client C1 by the neck in an attempt to have C1 get up to clean up the mess C1 made in the kitchen (refer to Confidential Names List LIC811 dated 10/11/24). LPA Silva reviewed the SIR and conducted telephone interviews with two (2) staff members, S1 and S2, on 09/26/24 and one staff member S3 on 09/30/24. The incident started when C1 grabbed things from the fridge and threw them on the floor, after C1 was told that he cannot make something out to eat because S2 was already making dinner. C1 then went to the office, sat down, and spoke to S3. S2 then entered the office and prompts C1 to clean up the mess he/she made in the kitchen. C1 refused and started cussing. S2 then walks over to C1 and grabbed C1 by the neck to have him/her get up and guide him out towards the office door. Before S2 and C1 got to the door, C1 fell to the ground as C1 was trying to resist or break away from S2. S2 stated that C1 intentionally dropped himself/herself to the floor as he/she did not want to walk. S2 then grabbed C1 by the arm to assist C1 to his/her feet and they walked out of the office. S1 stated that a meeting was held with the facility's Director, S1 and S2, to remind S2 about proper emergency intervention protocol. LPA was unable to interview C1 as C1 is no longer residing in the facility. LPA Silva also reviewed S2's file and checked for S2's qualifications and trainings as facility manager. Based on the information gathered from confidential interviews and records reviewed, a deficiency citation on STRTP Interim Licensing Standards, Personal Rights Section 87072(c )(32) is being issued (see LIC809D). An exit interview was conducted and a copy of this report and appeal rights were provided to Ms. Cotledge.


raw_content:
Narrative:
The Administrator admitted that the language used towards C1 sound bad and was meant to get on his level. The Administrator indicated that C1 had recorded the Administrator's responses. The Administrator indicated that she failed to provide trauma informed care in handling C1. Based upon the above, it is determined that the complaint is substantiated. The complaint is valid because the standard of a preponderance of evidence has been met. The facility is being cited for violation of the Interim Licensing Standards (ILS), Section 87072(c)(16), Personal Rights. To be free of physical, sexual, emotional, or other abuse, and from corporal or unusual punishment, exploitation, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature including, but not limited to, interference with the daily living functions of eating, sleeping, or toileting, or withholding of shelter, clothing, or aids to physical functioning.- (see 9099d) The LPA conducted an Exit Interview and provided a copy of this report, along with a Appeal Rights and Proof of Correction to the agency representative via email.

Investigation Findings:
On January 16, 2026 at 1:30 p.m., Licensing Program Analyst (LPA), Karen McGee, delivered the findings of the complaint investigation involving Client (C1)(see Confidential Names, LIC C1 dated January 16, 2025). The LPA met with Tiffany Cotledge. On September 9, 2025, Monterey Park Children's Residential Program (MPCRP), received a complaint with the above mentioned allegation. Confidential interviews were conducted that included, but were not limited to: the Administrator on September 18, 2025; and C1 at the new placement on December 12, 2025. The investigation revealed that there was an incident between C1 and the Administrator. The Administrator indicated that C1 was being argumentative about outings and medication early in the morning. The Administrator indicated that they began to go back and forth in a verbal argument. The investigation revealed that C1 used profanity and derogatory language toward the female staff. The Administrator admitted to responding to C1 utilizing the same profane language that C1 used at the Administrator and other female staff. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Karen McGee 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 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELOVED ONES 6FACILITY NUMBER: VISIT DATE: 01/16/2026

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


summary: Facility Evaluation

raw_content:
Narrative:
On April 7, 2026 at 12: PM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced case management inspection at the above facility and met with Administrator, Tiffany Cotledge (S1). The purpose of the inspection is to follow up on a Special Incident Report (SIR) received by the Department on 03/02/2026. The case management follow up (CM-2729-FN) is regarding a restraint incident that occurred on 02/28/26 involving staff (S1) and client (C1) (see Confidential List Form LIC811 dated 04/07/26). LPA Silva reviewed the Special Incident Report (SIR), Restraint Debriefing Report, Manual Restraint Log and the facility's Emergency Intervention Plan. LPA conducted telephone interviews with four (4) staff members, staff S1 on 03/16/26 and 03/26/26, staff S2 on 03/26/26, and staff S3 and S4 on 03/27/26. LPA also interviewed client (C1) via telephone on 03/26/26. LPA was unable to interview another client (C2), who was present at the time of the incident, due to C2 no longer resides in the facility. A video recording of the incident was requested by LPA. However, the facility's Director was unable to provide the video recording due to the camera was not working at the time of the incident. Based on information gathered through interviews and record reviews, the single person manual restraint conducted on client C1 is not according to the facility's Emergency Intervention Plan. The facility's Plan of Operation/Program Statement on Emergency Intervention states that a "single person manual restraint is dangerous, not supported by Pro-Act, and is not permitted at the facility". The facility is being cited for violation of Title 22, Division 6, Chapter 1, 80022(k) Plan of Operation, see LIC809D. Plan of corrections were discussed with the Administrator. An exit interview was conducted and a copy of this report, along with appeal rights, were provided to the Administrator.