summary: Facility Evaluation

raw_content:
Narrative:
On 01/29/2024 at 8: AM Licensing Program Analyst (LPA) Peete arrived unannounced at Home of Excellence Short Term Residential Therapeutic Program (STRTP) . The purpose of the visit was to amend the LIC 9099 and LIC 9099-C reports originally issued on 01/25/2024. A copy of this report was given to Facility Manager, Leticia Castaneda.


state: CA

facility_name: HOME OF EXCELLENCE

summary: Facility Evaluation

raw_content:
Narrative:
On Friday April 19, 2024 at 3: PM Licensing Program Analyst (LPA) Peete arrived unannounced to Home of Excellence Short Term Residential Therapeutic Treatment Program (STRTP) and met with Case Manager,Tijuana Ross to deliver a report. A copy of this report was given to the Case Manager.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Case Manager, Tijuana Ross


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Nicole Strickland arrived at the facility unannounced to conduct a Case Management - Other investigation. While at the facility LPA obtained the following documents: expense request for outings, photographs of daily log and conducted five interviews. LPA informed Facility Manager due to the need to gather additional information this investigation is being extended. The outcome of the investigation will be provided to Facility. An exit interview was conducted, and a copy of this report was provided to Facility Manager, Leticia Castaneda.

met_with: Leticia Castaneda.


summary: Facility Evaluation

raw_content:
Narrative:
On June 26, 2024 at 9: AM, Licensing Program Analyst's (LPA's), Emina Preciado and Rachel Vanegas, arrived at Home of Excellence Short Term Residential Therapeutic Program (STRTP) to conduct an unannounced annual inspection. LPA's met with Facility Administrator, Tiffany Merritt, and conducted an inspection of the facility with Facility Manager, Leticia Castaneda. LPA's inspected the facility inside and out with facility manager. The facility consists of three bedrooms and two bathrooms. One bedroom is used as the staff office and has a restroom inside that is also available for clients to use. The facility has a dining area, a kitchen area, a living room, a staff office, laundry room, and a garage. The laundry room is located off the hallway. The bedrooms are arranged so that there are two clients sharing a room and one client per bed. There is adequate closet space for client's belongings. There are currently three clients at the facility. LPA observed two mattresses, in bedroom three. There is one open bed and one bed that is occupied. Bedroom two is currently vacant and does not have any clients. Bedroom one is located near the kitchen across the hall and is occupied with two clients. The bathrooms were observed to be clean and in good repair. The hot water in both bathrooms were within the appropriate range of 105 degrees to 120 degrees Fahrenheit. Cleansers/chemicals are locked and stored in the laundry room cabinets; additional cleaning supplies are locked in the staff office. Sharp knives are inaccessible and stored in a locked hall closet. The smoke and carbon monoxide detectors were operable, the fire extinguishers were observed to be fully charged and in working condition. There are no guns or weapons on facility grounds as stated by the Administrator. LPA's observed facility posted items in the entry way and dining area that included: Grievance Procedures, Personal Rights, Visitation policies, Foster Care Ombudsman, and current food menu. Client's medications were observed to be inaccessible and stored in the locked hall closed, inside a lock box. LPA's observed a variety of food stored in the refrigerator and kitchen cabinets. LPA's observed a minimum seven day non-perishable and a two day perishable supply of food. * LIC 809-C* There are no pools or other bodies of water on the property. There is adequate indoor and outdoor activity space; all exits, and walkways were free from obstruction. LPA's observed age-appropriate toys, games, and books for client's recreation time. LPA's reviewed the Physical Plant, Disaster Preparedness, Operational Requirements, and Core Therapeutic Services. Due to time constraints, LPA's will return to complete the inspection at a later date. Based on observation and record review, all documentation pertaining to this area of the inspection was provided, and no deficiencies were noted at this time. An exit interview was conducted, and a copy of this report was provided to Facility Manager, Leticia Castaneda.

visit_type: Annual

met_with: Leticia Castaneda, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On June 28, 2024, at 09: AM, Licensing Program Analysts (LPA's), Rachel Vanegas and Emina Preciado, arrived unannounced at Home of Excellence, Short-Term Residential Therapeutic Program (STRTP). LPAs met with Facility Manager, Leticia Castaneda, to continue an annual inspection that was initiated on June 26, 2024 when LPAs conducted a review of the Physical Plant, Disaster Preparedness, Operational Requirements, and Core Therapeutic Services. During today's inspection, LPAs completed the review of Staffing Records, Client Records, and Emergency Intervention Plan. LPAs reviewed five staff files S1, S2, S3, S4, and S5 and three client files C1, C2, and C3. Five out of five staff that work at the facility have Department of Justice, Child Abuse Clearance Index clearances, and current CPR/First aid certification. During staff file reviews, four out of five staff files reviewed did not have a Tuberculosis (TB) test on file. Two out of three client files reviewed, did not have a documented medical assessments or TB testing on file within 30 days of placement. As part of the annual inspection, LPAs conducted staff and client interviews. Based on observation and record review, the facility is being cited two Type B violations in accordance with California Code of Regulations (CCR) (Title 22) 80066(a)(11) for S1, S2, S4, and S5 not having a TB clearance documented on file and section CCR 80069(c)(1) for not having the results of medical/TB examination on file for C1 and C2 prior to or within 30 days of admission to the STRTP. **Continued on 809-C** Additionally, the facility is being issued six technical violations in accordance with Interim Licensing Standards (ILS) 87070(c)(1) for Needs and Services Plan (NSP) missing signatures from the authorized representative for C2, ILS 87068.2(b)(6) for C1 and C2 not having visitation frequency or other limitations on visits to family residence and other visits on their NSPs, ILS 87068.2(f) for C1 and C NSPs not mentioning or discussing the integration of family members in the clients' treatment process, ILS 87095.65(d)(1)(A) for staff training certifications not including hours of training completed, ILS 87065.1(e)(1) for the STRTP not having 40hours of annual training certificates for staff records available for review and verification for S1 - S5, and CCR 80069(a) for C1 and C2 not obtaining a written medical assessment prior to or within 30 days of acceptance at the STRTP. Exit interview conducted and appeal rights were reviewed and provided. A copy of this report along with LIC 811 - Confidential Names List, were provided to the Facility Manager, Leticia Castaneda.


summary: Facility Evaluation

raw_content:
Narrative:
On April 17, 2025, Licensing Program Analyst (LPA) Sarah Lo arrived unannounced for the purpose to conduct interviews regarding a complaint allegation unrelated to this facility. LPA arrived and met with Leticia Castaneda, Facility Manager, and was allowed entry into the facility. LPA conducted three interviews during this visit.


summary: Facility Evaluation

raw_content:
Narrative:
On April 30, 2025, Licensing Program Analyst (LPA) Adaleyci Caballero arrived at the facility to conduct an interview regarding an incident unrelated to this facility. LPA met with Facility Manager Leticia Castaneda who granted LPA access to the facility. A copy of this report was provided to Leticia Castaneda.

met_with: Facility Manager-Leticia Castaneda


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Sethany Yem conducted a case management inspection on 9/17/25 at 12: PM based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 5 out of Direct Care Staff and 5 out of 5 youth files were reviewed. 2 out of Direct Care Staff and 1 out of 5 youth were interviewed. (See the Confidential Names List, LIC 811, 9/17/25). The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings minutes was reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth case plans, and crisis intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA observed training records that show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to AdministratorTiffany Merritt.

met_with: Administrator Tiffany Merritt


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Specifically, it was reported that C1 has self-harm history and was transported to the hospital due to using a razor to cut themselves and it is unknown how C1 obtained the razor. Although the Department received detailed information, the confidential interviews provided inconsistent statement and did not provide sufficient evidence to corroborate the allegation. Confidential interviews entailed that C1 was on a safety plan which consisted of staff conducting five-minute check-ups on C1. Other confidential interviews revealed that staff would check on C1 every fifteen minutes. It is unknown if staff were following the safety plan. Based on confidential interviews and video observation, the allegation that staff are not providing proper supervision to C1 exhibiting self-harming behavior, may have occurred, however, is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with appeal rights was provided to Home of Excellence Short Term Residential Therapeutic Program (STRTP), Leticia Castenada, Facility Manager.

Investigation Findings:
13On December 17, 2025 at 01: PM, Licensing Program Analyst (LPA) Sarah Lo met with Leticia Castenada, Facility Manager, to deliver the finding for the above complaint allegation at Home of Excellence Short Term Residential Therapeutic Program (STRTP). On 08/12/25, LPAs Sarah Lo and Gilbert Marquez inspected the facility's physical plant, and no immediate health and safety hazards were observed. The investigation included interviews with two staff (S1, S2), six clients (C1, C2, C3, C4, C5, C6) and three County Social Worker (CSW1, CSW2, CSW5). In addition, the Clients' Needs and Services Plans were reviewed. On August 11, 2025, Community Care Licensing received an allegation that staff are not providing proper supervision to minor (C1) exhibiting self-harming behavior. (continued on LIC 9099c) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Sarah Lo 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 61-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: HOME OF EXCELLENCEFACILITY NUMBER: VISIT DATE: 12/17/2025

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

report_type: Complaint Investigation

met_with: Leticia Castenada, Facility Manager

complaint_status: unsubstantiated


raw_content:
Narrative:
**Continued from LIC9099** Regarding the allegation that staff did not safeguard C2's belongings, confidential interviews revealed that S4 was distracted when C1 and C3 went into the room of C2 and destroyed it, and other confidential interviews revealed that S4 did nothing to prevent C1 and C3 from destroying property of C2. Although the Department received detailed information, the confidential interviews provided inconsistent statements that would validate the allegations. Based on inconsistent interviews the allegations that due to lack of supervision, C1 engaged in an altercation with C2, and staff did not safeguard C2's personal property may have occurred, however, is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights were explained, and a copy of this report, appeal rights and LIC 811 was provided to STRTP Home of Excellence Administrator Facility Manager Cynthia "Leti" Casteneda.

Investigation Findings:
13On 12/31/25 at 9: AM, Licensing Program Analyst (LPA) Gilbert Marquez and met with Short Term Residential Treatment Program (STRTP) Home of Excellence Facility Manager Cynthia "Leti" Casteneda to deliver the findings for the above-stated allegations. On 11/06/ LPA inspected the facility, and no immediate health and safety hazards were observed. The investigation included interviews with Staff (S1, S2, and S3), see Confidential Names List, LIC 811, dated 12/31/2025, Clients (C1, C2, C3, C4), and a County Social Worker (CSW). In addition, client records and the facility files were reviewed. On 10/30/2025, Community Care Licensing (CCL) received a complaint alleging that due to lack of supervision, C1 engaged in an altercation with C2, and staff did not safeguard C2's personal property. Confidential interviews revealed conflicting statements. Confidential interviews revealed that C1 and C2 were aggravating each other prior to the altercation, which was stopped by S1, and other confidential interviews revealed that C3 was the first to stop the fight. **Continued on LIC9099C** UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Gilbert Marquez 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 61-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: HOME OF EXCELLENCEFACILITY NUMBER: VISIT DATE: 12/31/2025

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


summary: Facility Evaluation

raw_content:
Narrative:
On June 30, 2021 at 10: AM, Licensing Program Analyst (LPA) Carmen Escobar arrived at Home of Excellence Residential Therapeutic Program (STRTP). LPA was greeted and granted access by facility manager (FM) Ms. Leticia Castaneda. The purpose of the visit is to conduct an annual inspection of the facility. There were two staff and five clients present at the time of the inspection. Appropriate staff/client ratios were verified during the inspection. At 10: AM, Ms. Leticia Castaneda led the physical inspection of the facility with LPA Escobar. The facility consists of four bedrooms and two bathrooms. One bedroom is used as the staff office and has a restroom inside that is also available for clients to use. The facility has a dining area, a kitchen area, a living room, a staff office, laundry room, and a garage. The laundry room is located off the hallway that leads to the garage. There is a new addition to the back porch area that will be used as the clinician's office for therapeutic services as well as the case manager's office. These services are currently being offered in the staff office space. There are windows and a fan within the addition. All bedrooms have individual beds and drawer space for each client. The facility ensures that there is one client per bed with appropriate linens, pillows, comforters, and mattresses in good repair. All the bedroom windows are missing screens. Facility grounds are clean and free of debris and observable hazards. During the inspection, it was observed that there is an old, disconnected satellite on the ground, creating a potential hazard. There is adequate indoor and outdoor activity space. Televisions, a computer, board games, video gaming console, trampoline, punching mannequin and punching tower bag, and books, were observed for client's recreation time. There is an activities calendar posted and staff are getting back to scheduling outings and outside activities. Carbon monoxide detector is in appropriate working order and facility smoke detectors are also in working order. Fire extinguisher is properly charged and serviced. The facility maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. There is an extra freezer in the garage along with an extra refrigerator. An addition was also built off the dining area that is used as a pantry and storage area. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster. Medications are stored in a locked box within a locked closet in the hallway. The hot water in the staff and client restrooms was deemed to be at a safe temperature. Per facility staff, there are no firearms or weapons in the facility. Chemicals and/or poisons are locked in a cabinet above the washer/dryer in the laundry area. Sharp objects/knives are stored in a locked box in the locked closet in the hallway. First Aid Kits are also stored in this locked closet and are complete. A First Aid Manual was also available. It was observed that the licensee has cameras in common areas of the facility as well as the staff office, outside facing the front door and in the backyard facing the windows and side wall. There is an exception on file for the facility to use the cameras and the facility continues to meet the terms and conditions of the exception. The facility employs one Facility Administrator, three Facility Managers/Acting Managers, seven direct care youth counselors, two Case Manager, one Head of Service and one Program Director. Facility has not yet obtained Mental Health Certification, however, have submitted the application and are awaiting approval. Facility has obtained National Accreditation through CARF effective through February 28, 2022. Currently, the facility is up to date with Licensing fees for the facility, with a balance of $0. At 11: AM, six of six client files were reviewed during time of inspection. Client files are kept in a locked file cabinet within the staff office. Client 1 (C1), client 2 (C2), client 3 (C3), client 4 (C4), client 5's (C5), and client 6's (C6) files were reviewed at time of inspection, (See LIC 857) dated June 30, 2021. C1 and C2 did not have medical consent form in files. C6 did not have a current JV220 in file or a pending JV220 application. The facility will be cited under Interim Licensing Standards section Children's Records. C6 did not have a current needs and service plan in file. A Technical Assistance Advisory Note (TA) will be issued. LPAs conducted client interviews. Clients indicated that their basic needs are being met at the facility and core services being provided as well. LPA Escobar began the review of staff files, however, due to time constraints, was not able to conclude the review. LPA Escobar will return to complete staff file review and interviews at a later date. An exit interview was conducted and a copy of this report and appeal rights were provided to Facility Manager, Ms. Leticia Castaneda.

met_with: Facility manager-Leticia Castaneda


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On July 1, 2021, at 9: AM, Licensing Program Analyst (LPA) Carmen Escobar arrived at Home of Excellence Short-Term Residential Therapeutic Program (STRTP). The purpose of the inspection was to complete the continuation inspection for STRTP annual inspection that was initiated on June 30, 2021. LPA already completed the physical inspection of the facility and reviewed facility client files on the first day of the annual inspection. During this annual inspection continuation, LPA Escobar reviewed ten personnel files to ensure they contained all required documentation per Title Regulations and Interim Licensing Standards (ILS). Personnel Files are usually maintained in a locked closet inside the staff office. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Nine of the ten files that were reviewed were for employees who converted from group home personnel to STRTP personnel. LPA observed the converted staff members were trained according to the STRTP training requirements. Files for staff 1 (S1), staff 2 (S2), staff 4 (S4), staff 5 (S5), staff 6 (S6), staff 7 (S7), staff 8 (S8), staff 9 (S9), and staff 10 (S10) did not have employer verification form in files. S7 did not have a copy of Driver's License in file, but had DMV print out in file. S5, S7, and S8, did not have signed record of having received copy of Employee Handbook. S3 did not have job evaluation in file. Technical advisories (TA) will be issued for these file issues. S5 did not have proof of current CPR/first aid in file, facility will be cited under Title 22 section 80075: Health Related Services. S2 and S8 did not have record of new hire training or orientation hours in files. Facility will be cited under ILS section 87065. Training Requirements. Administrator Tiffany Merritt is present at the facility a minimum of 20 hours a week, as verified by staff schedule and interviews. Appropriate staff/client ratios were verified during this inspection. LPA discussed the following with the Administrator and Facility Manager: incident reporting, including incidents related to Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. LPA discussed procedures for Child and Family Team (CFT) meetings, including an overview of required Core Services and Supports. One youth counselor (direct care staff) and two Facility Managers, present during annual inspection, were interviewed in regard to their job duties, training, and services provided at the facility. All staff were able to provide sufficient information in relation to the facility's STRTP program. Staff have no issues or concerns regarding the facility. Based upon the inspection of facility records and interviews with staff and clients, the Licensee appears to be meeting CFT and Core Services/Supports requirements. LPA requested the recent board meeting minutes be provided via email by July 7, 2021. A copy of this report, the advisory notices, and appeal rights, were provided to Facility Manager, Leticia Castaneda.

Deficiencies:
80075(f): (f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

title:
1
2
3
4
5
6
780075(f) Health Related Services


summary: Facility Evaluation

raw_content:
Narrative:
On February 2, 2023, at 3: PM, Licensing Program Analysts (LPAs), Carmen Escobar and Lisi Leon conducted an in-person inspection of Home of Excellence Short Term Residential Therapeutic Program (STRTP). The purpose of the inspection was to conduct a physical walk through of the facility to inspect building and grounds. While LPA conducted a physical inspection of the facility, it was observed that room 1, room 2, and room 3, do not have doors. The doors have been replaced with curtains. By removing all the bedroom doors, the facility is in violation of clients' personal rights. The facility is being cited under Interim Licensing Standards (ILS) section 87072, Personal Rights. An exit interview was conducted and a copy of this report, along with appeal rights, was signed by, and provided to Facility Manager, Leticia Castaneda, via facility email due to technical difficulties.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Leslie Covarrubias on January 26, 2024 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Covarrubias met with Tijuana Ross, Case Manager and inspected the facility inside and out. LPA reviewed one of child's records and two of staff personnel files at the facility. LPA reviewed one of child's psychotropic medications and medication records. LPA interviewed two of staff to discuss the facilities policies and procedures of operation. LPA interviewed zero of children currently prescribed psychotropic medication. One child refused to be interviewed. During the inspection the LPA observed deficiencies (see attached 809D), plan of corrections were discussed and appeal rights were provided. LPA provided a copy of this licensing report to Tijuana Ross, Case Manager.

met_with: Tijuana Ross, Case Manager


facility_name: HOPE REFUGE, INC

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
C1 stated that S4 rubbed his hand on her right shoulder even though C1 told her not to, and it made C1 feel uncomfortable. Clients confirmed seeing S4 rubbing his hand on C1's right shoulder. Facility staff stated that the clients informed them of the incident immediately and staff reported the incident to S1. In addition, S4 said that he doesn't recall rubbing his hand on C1's shoulder. Based on LPA interviews and record reviews, the preponderance of evidence standard has been met, therefore the allegations are found to be SUBSTANTIATED. A deficiency was cited to the facility for Personal Rights Violation. Exit interview was conducted with the Administrator. Due to technical difficulties, Appeal Rights and a copy of this report will be send via e-mail to the licensee for signature.

Investigation Findings:
13On April 30, 2021 at 9: AM, Licensing Program Analyst (LPA) Enrique Hernandez made an announce inspection to Hope Refuge Short Term Residential Therapeutic Program (STRTP), the purpose of the visit is to conclude the investigation on the above allegations and to deliver the findings. LPA spoke with Staff #1 (S1) and together discussed the investigation details in a phone call due to administrator of the facility not been present. During the course of the complaint investigation, all relevant parties were interviewed. The interviews produced corroborating evidence for the allegations above. C2 stated that S4 made an inappropriate comment that made her feel uncomfortable. The clients of the facility confirmed that they heard S4 tell C2 "come and entertain me". S4 stated that he doesn't recall making that comment. Staff also confirmed that the clients informed them about how uncomfortable they felt after hearing S4 make that comment to C2. Continue on LIC 9090-C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: VISIT DATE: 04/30/2021

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

met_with: Staff #1

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13On May 4, Out of State Group Home Analyst Sarah Waklee conducted and announced telephone call with Hope Regue INC. Facility Administrator. Analyst Waklee was unable to interview the alleged vicitim due to her being AWOL. Based on confidential interviews with three staff memembers and one youth, Analyst Waklee determined that the allegation is unsubstantiated. An unsubstantiated finding means although the allegation may have happened, the preponderance of evidence does not prove it. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Sarah Waklee 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 2

met_with: Sharon Stevens


raw_content:
Narrative:
Before S4 left the hospital, S4 informed the nurses not to let C1 go with A1, because A1 is not C1's legal guardian. A1 stated that when she arrived at the hospital A1 did not see any staff member with C1, S3 confirmed that S4 had already left by the time S3 arrived at the hospital. In Addition, SW said that C1 should not be left alone with A1,because the in-person visits of A1 with C1 must be supervised. SW is concern that the facility staff left C1 be alone in the hospital. Based on LPA interviews and record reviews, the preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. A deficiency was cited to the facility for Neglect Lack of supervision. Due to repeat deficiency 80078(a) within 12 months, a civil penalty will be issue of $250 and $100 a day until the violation is corrected. Exit interview was conducted with the Administrator, Appeal Rights and a copy of this report will be send via e-mail to the licensee for signature.

Investigation Findings:
13On May 26, 2021 at 11:50am Licensing Program Analyst (LPA) Enrique Hernandez made an unannounced Telephone call inspection to Hope Refuge Short Term Residential Therapeutic Program (STRTP), the purpose of the call is to conclude the investigation on the above allegation and to deliver the finding. LPA spoke with Facility Administrator Sharon Stevens and together discussed the investigation details. During the course of the complaint investigation, all relevant parties were interviewed. The interviews produced corroborating evidence for the above allegation. Based on the interviews with C1, S1, S2, S3, S4, S6, A1 and SW It was confirmed that C1 had to go to the hospital and the staff did not follow the ambulance, because S4 lost the keys to the vehicle. C1 was upset that no one was in the hospital with her. S4 and S3 stated that they tried to contact S1 and S2 several times to find out what to do, and who was going to the hospital. After a couple of hours of C1 been in the hospital alone, S4 arrived at the hospital. S2 authorized S4 at 12:14 am to go home, because S3 was heading to the hospital to relieve S4. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: 425802135

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


raw_content:
Investigation Findings:
13On 8/06/2021 at 8:45am Licensing Program Analyst (LPA) Enrique Hernandez made an unannounced inspection to the above facility, for the purpose of concluding the investigation on the above allegation and to deliver the findings. LPA spoke with the facility Program Manager Taylor Abernethy and the licensee Sally Cook, and together discussed the investigation details. During the course of the complaint investigation, all relevant parties were interviewed. Staff and clients confirmed, that the doors to both medicine cabinets where were left open. S6 confirmed that S6 left the two doors open of the medicine cabinet because, was attending the emergency of another client. S6 said it was a mistake to leave both doors open.C1 indicated taken medicine out of the cabinet as soon as C1 saw that it was left open. The facility staff responded by calling Immediately emergency services for C1. Based on LPA interviews and record reviews, the preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. A deficiency was cited to the facility for Health-Related Services. (See 9099-D) Exit interview was conducted and a copy of this report was left at the home with the Licensee whose signature on this form confirm receipt of this document. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: 425802135

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

met_with: Licensee


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
continued from page 1 (LIC 9099) Medications are being mismanaged. In staff and client interviews it was confirmed that medications were given at the wrong time or missed because there wasn't a staff to administer them. It was also reported during an emergency, a staff left the med closet open and a client was able to access her meds to attempt an overdose. In other reports it was disclosed by staff and clients, and facility documentation, that a client was able to self-harm by putting bleach and other chemicals in her mouth, as well as reports of clients self-harming by cutting themselves. Based on LPA interviews and record reviews, the preponderance of evidence standard has been met, therefore the allegations are found to be SUBSTANTIATED. A deficiency was cited to the facility for Personnel Requirements and Health-Related Services (See 9099-D). Exit interview was conducted, signature from Facility Representative was received, and a copy of this report was left at the facility.

Investigation Findings:
13On August 15, 2021 at 12: PM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard made an unannounced inspection to the above facility for the purpose of concluding the investigation and to deliver findings. Upon arrival, AGPA Woodard was greeted by Jackie George, Facility Manager. During today's visit, investigation details were discussed. During the course of the investigation, relevant parties were interviewed, staff files and other facility records were reviewed. Staff and clients confirmed activities are minimal. Weekly they will have a volunteer come and do art therapy. On occasion they can use the pool, or they will go to the beach after church on Sunday. However, if they choose not to go to church, they can't go to the beach. There are no planned activities, and other activities that require to be purchased are denied and staff will try to get activities donated. continue on page 2 (LIC C) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard 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 34-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, N. Continental Blvd. #290B FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: VISIT DATE: 08/15/2021

met_with: Jackie George, Facility Manager


summary: Complaint Investigation - Substantiated - 1 deficiency

raw_content:
Narrative:
continued from page 1 (LIC 9099) other machine smells like a dead animal; (Photo of two dryers with do not use were taken on June 5, 2021). Also observed by AGPA trash bins outside of cottages were overflowing, trash dumpsters by front gate were overflowing, and trash cans in Stone House were full; (Photo taken of trash bin on June 5, 2021 and trash dumpster on 08/14/2021). Staff and clients both state that the facility is hazardous due to the location poses a hazard if there was a fire, and broken glass and screws are often found on the ground. On 08/06/2021, during a case management inspection, LPA observed a chainsaw on the ground located near stone house along the path. Although the staff to client ratio is 1:4, there is not enough staffing to meet the needs of the girls. There are incidents where clients are self-harming, clients will request to go to the doctor/hospital and will have to wait because of not enough staff, and a client was left at the hospital without a staff. Based on AGPA interviews and record reviews, the preponderance of evidence standard has been met, therefore the allegations are found to be SUBSTANTIATED. Deficiencies were cited to the facility for Plan of Operation, Personal Services, Building and Grounds, Transportation, Health and Safety Code, and Furniture, Fixtures, Equipment, and Supplies (See 9099-D). Exit interview was conducted, signature from Facility Representative was received, and a copy of this report was left at the facility.

Investigation Findings:
13On August 15, 2021 at 12: PM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard made an unannounced inspection to the above facility for the purpose of concluding the investigation and to deliver findings. Upon arrival, AGPA Woodard was greeted by Jackie George. During today's visit, investigation details were discussed. During the course of the investigation, relevant parties were interviewed, staff files and other facility records were reviewed. Staff and clients confirmed, that the majority of staff hired have no previous experience and are not properly trained on procedures. The majority of staff and all clients interviewed do not know the evacuation plan. If there is an evacuation plan in place, they are not aware of it, and emergency drills are not being performed. Facility Vehicles are dirty inside and out and require maintenance; oil light was on for weeks and it was reported that the facility vehicles have run out of gas. On June 5th, AGPA observed two out of three dryers that were out of order. Both staff and clients say one of the dryers has flames and the continue on page 2 (LIC 9099C) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard 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 34-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, N. Continental Blvd. #290B FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: VISIT DATE: 08/15/2021

Deficiencies:
87022(f): Be appropriate to meed the needs of staff and population(s) being served.

title: The facility shall operate in accordance with the terms specified in the plan of operation and may be cited for not doing so. A plan for the supervision, evaluation, and training of staff. The training plan shall


raw_content:
Investigation Findings:
13On August 21, 2021 at 1PM Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted an unannounce complaint inspection at the above facility for the purpose of delivering findings. Upon arrival, AGPA Woodard was greeted by Stephanie Reteria-Perez, Facility Manager. During the course of the investigation, relevant parties were interviewed, and an inspection was conducted. Staff and clients did not confirm that toiletries were not provided. Statements varied. Shampoo, conditioner, body wash, etc. are being provided, however on occasion they run low in stock on personal hygiene items such as tampons. Items that run low in the cottages are able to be refilled from the storage area near the stone cottage where overstock is kept, such as toilet paper, paper towels, cleaning supplies, etc. Durning inspection of the facility, AGPA observed personal hygiene items/toiletries in an office located in the dining hall as well as the storage room near the Stone House. Based on AGPA interviews and observance of toiletries, the preponderance of evidence standard was not met, therefore the allegation is found to be unsubstantiated. A finding that the complaint is unsubstantiated means that the allegation may have occurred, however not supported or proven by evidence. A copy of this report was left at the facility and emailed to Sally Cook. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Sally Cook


raw_content:
Narrative:
Additionally, clients and staff confirmed that if a client's starts vandalizing the facility, staff are always there to intervene and to make sure no one gets injured. Clients confirmed that they receive group and individual therapy at the facility, which was confirmed by facility staff. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. The Department has decided that the above allegations are unsubstantiated but if any additional information is received this complaint can be amended and findings can be changed. Per California Code Regulation, Title 22, Division 6, Chapters 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), there are no deficiencies to be cited at this time. Exit interview was conducted and a copy of the report will be email to the licensee due to technical difficulties with LPA computer at the time of the inspection.

Investigation Findings:
13On August 25, 2021, at 11:00 am, Licensing Program Analyst (LPA) Enrique Hernandez made an unannounced visit to the above facility for the purpose of concluding the investigation on the above allegations and to deliver the findings. LPA met with the licensee, and due to computer issues LPA was not able to discuss the findings with the licensee until August 26, 2021 via telephone. Based on the confidential interviews with all the pertinent parties and file review, the allegations cannot be substantiated, although interviews with C4 and C5 confirmed that they smoked a small marijuana cigarette at the facility, staff tried to intervene to prevent clients from continuing to smoke the cigarette. C4 stated that as punishment C4 had to go to the room but does not remember for how long. C5 denied being in the room as a form of punishment for smoking. The facility staff confirmed that they do not send clients to their rooms as a form of punishment. Facility staff confirmed that there is a level system in place and clients lose points if they do something bad like smoking marijuana or if they AWOL from the facility. During LPA's inspection on 6/9/2020 at the facility, LPA did not observe locks on the client's room doors. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: VISIT DATE: 08/25/2021

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


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

raw_content:
Investigation Findings:
On September 4, 2021 at 12:45PM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted an unannounced complaint inspection at the above facility for the purpose of delivering findings. AGPA met with Stephanie Renteria-Perez, Facility Manager. During the course of the investigation, AGPA Woodard conducted confidential interviews with staff, clients and other relative parties. Staff state they will use their own money for facility related projects, gasoline, oil changes, food, etc. and it takes about 1-3 weeks to get reimbursed. 95% of the food at the facility is purchased from the food bank. When interviewing the CEO he stated there were no outstanding reimbursements, but in other interviews reimbursements are up to $70,000 pending. CEO signs off on his and the Executive Director's reimbursements, however Balance Financial Services states that "Executive team members do not approve their own expenses. Reimbursements are approved by another manager." Based on interviews and documentation received through the course of this investigation, the preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. A deficiency was cited to the facility for Finances (See 9099-D). Exit interview was conducted, signature from Facility Representative was received, and a copy of this report was left at the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard 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 34-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, N. Continental Blvd. #290B FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: 425802135

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

Deficiencies:
80062: (1) Development and maintenance of a financial plan which ensures resources necessary meet operating costs for care and supervision of clients.

met_with: Stephanie Renteria-Perez

title: (a)The licensee shall  meet the following financial requirements


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
The investigation revealed during a facility outing on May 8, 2021, S1 provided alcohol to clients C1 and C2. Confidential interviews revealed S1 gave C1 a mixed alcoholic drink which S1 provided to clients in a pink colored plastic bottle. C1 indicated that C1 "got a buzz" from the alcohol as a result. Witness statements remained consistent throughout the investigation process. S1 denied providing alcohol to the minors. Upon discovery of the incident, facility filed an incident report notifying required parties and conducted an internal investigation into the matter. It was also revealed during the same outing, S1 took out an unlit marijuana cigarette and put in S1's mouth "jokingly". Upon facility's discovery of S1's actions, S1 was place on suspension and later terminated from facility's program. According to witness statements and documentary evidence, S1 allowed C1 and C3, to use S1's cell phone to message through outside communications and/or post selfie. Evidence of C3's photo and/or messages was observed posted in social media. The investigation revealed that S1 knew C1, C2 and C3 were victims of Child Sex Trafficking; however, S1 allowed minors to use S1's cell phone to post messages and potentially communicate with sex traffickers. Based on confidential interviews and documentary evidence, the Department has determined the allegations that S1 provided alcohol to minors to consume and exposed minors to CSEC activity is Substantiated. Staff's actions poses an immediate health, safety and personal rights risk of harm to children placed in care. The licensee is therefore issued a citation in accordance with the Short-Term Residential Therapeutic Program Interim Licensing Standards, Chapter 7.5, Version 3.1: 87065. Personnel Duties. See page LIC9099-D for citation. An exit interview was completed and appeal rights discussed. A copy of this report was emailed to Program Manager.

Investigation Findings:
13On September 23, 2021 at 2: PM, Licensing Program Analyst (LPA) Regina Martin conducted a subsequent complaint inspection at the above facility for the purpose of delivering findings. LPA met with Taylor Abernethy Program Manager and together the findings are discussed. On May 17, 2021, Community Care Licensing received a complaint alleging Staff Member #1 (S1) provided alcohol to minors and S1 exposed minor to CSEC (Commercial Sexually Exploited Children) activity. The complaint was referred and assigned to Investigations Bureau, Investigator, Olivia Spindola. [see Confidential Names form, LIC811, dated 9/23/2021]. During the investigation confidential interviews were conducted with facility residents, Client #1 (C1) and Client #2 (C2), staff members, assigned Probation Officer for C1 and S1. (Continued on page LIC9099-C) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Regina Martin 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 34-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, N. Continental Blvd. #290B FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: VISIT DATE: 09/23/2021

met_with: Taylor Abernethy Program Manager


raw_content:
Narrative:
Based on statements gathered and review of related documents including review of police report, facility incident report, and client's file, there is not enough evidence to support a lack of supervision resulted in C1's attempted hanging. Records reviewed revealed C1 had a history of self harming behavior and Hope Refuge had safety measures in place to help de-escalate C1. At the time of the incident on September 2, 2020, the facility was operating within approved staff to client ratios. C1 was assigned one to one supervision with a designated staff member. Staff members acted swiftly and appropriately to prevent C1 from harming self or any staff members. Based on statements gathered and review of related documents including review of police report, facility incident report, and client's file, there is not enough evidence to support a lack of supervision resulted in C1's attempted hanging. It was further reported that Staff are not properly trained and Staff are not meeting minor's needs. Information obtained during interviews and record review revealed that while staff members receive standard ongoing training including, but not limited to Pro-Act (Professional Assault Crisis Training) some staff members lack experience working with youth in current population resulting in high turnover and continual hiring of new staffs. Based on gathered information, the finding concerning above mentioned allegations are deemed Unsubstantiated at this time meaning, although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. There were no deficiencies cited at this time. A copy of this report is emailed to Program Manager.

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

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


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
continued from 9099 taking four bubble packs of medication out of a med box (Hydroxyzine 10mg and Dicyclomine 20mg), ability to ingest bleach and other chemicals, and the ability to take items from a first aid kit that included a small sharp edge tool while at the facility pool. The evidence revealed the county placement agency did not receive a notification from Hope Refuge about the incident of discovering three box cutters in the child's possession until after an inquiry was made. Based on confidential interviews and documentation reviewed through the course of this investigation, the Department has determined that the licensee has failed to prevent minor from having access to hazardous items while in care, did not prevent youth from self-harming, and failed to report the incident within the agency's next working day. In most cases staff are not aware incidents of self-harming have occurred, that items have been found that can be used for self-harm, etc. until a client has informed them. Staff's actions pose an immediate health, safety and personal rights risk of harm to children who are placed in care. The licensee is therefore issued a citation in accordance with STRTP ILS, Chapter 7.5, Version 3.1 - 87065. Personnel Duties, and General Licensing Requirements, Ch. 1 - Reporting Requirements. (See 9099D). An exit interview was conducted, signature from facility representative was received, and a copy of this report was left with Kyla Landow.

Investigation Findings:
13On September 26, 2021 at 9:45AM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted an unannounced subsequent complaint inspection at the above facility for the purpose of delivering findings. AGPA met with Kyla Landow, Direct Care Staff and together the investigation details were discussed. During the investigation process, AGPA conducted confidential interviews with past and present staff, clients, reviewed client records, and gathered supportive documentation. The investigation revealed that during the course of C1's stay at the facility, she had multiple incidents that involved self-injurious behavior, which included having access to hazardous items such as box cutters, screws, pieces of broken glass, blades, access to an unlock medication cabinet which resulted in her SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard 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 34-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, N. Continental Blvd. #290B FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: VISIT DATE: 09/26/2021

met_with: Kyla Landow


raw_content:
Narrative:
continued from At time of licensure, there were only A/Cs and heaters in the cottages and school. Space heaters were provided to staff as needed for other areas of the facility with no heating. A/Cs were installed in the Administrative Offices, Music Room, and the Mental Health Building earlier this year. There is approximately 214 acres of property that needs to be maintained and there is currently one maintenance staff who trims the trees and bushes and removes the dried brush along with other assigned duties. During the time of the initial report, the facility employed two maintenance staff. The Septic tank was serviced last on January 6, 2021. There was a plug in the line beneath the tiny house which created a smell near the upper area of the facility near Stone House and adjacent buildings, however it was fixed immediately. In one interview it was disclosed that the smell was around Pine and Oak cottages. In January staff observed a rodent in the Administrative office, however it was caught and removed. Gaps were filled with foam, and rat/rodent bait boxes were placed around the outside perimeter of the buildings throughout the facility. In July, a rat was observed in the dining hall, which was captured. The facility utilizes Dash Pest Control treatment which includes spraying for bugs and spiders. There was one report of a leaky fire hydrant near Pine, and reports of no hot water in the Bath House and plumbing in Olive Cottage was in disrepair. Based on confidential interviews and statements and supportive evidence obtained during the investigation process, the allegations cannot be corroborated. Although the allegations may have happened or valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. The Department has determined that the Physical Plant allegations are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. continued on 9099-C Per California Code of Regulations, Title 22, Division 6, Chapter 1, Article 07 (General Licensing Requirements), Section 80087, there are no deficiencies noted or cited. An exit interview was conducted, and a copy of this report was left at the facility.

Investigation Findings:
13On November 13, 2021 at 9: AM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted an unannounced complaint visit to Hope Refuge and met with Direct Care Staff, Trina Garcia for the purpose of concluding the investigation. AGPA Woodard conducted several visits to Hope Refuge from June 5, 2021 through October 28, 2021. The facility was approved for licensure on November 8, 2019. AGPA Woodard obtained eleven (8) confidential statements from 4 clients and 4 staff. AGPA received supportive documentation from the licensee. Reporting Party was unable to be interviewed due to being anonymous. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard 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 34-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, N. Continental Blvd. #290B FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: VISIT DATE: 11/13/2021

met_with: Trina Garcia


raw_content:
Narrative:
Facility staff locked resident out of facility. Confidential interviews revealed that no staff locked clients in the cottage. Although Client # 1 (C1) reported that staff locked the cottage with C1 inside. During the confidential interviews, no witness could corroborate seeing C1 locked up inside the cottage. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. The Department has decided that the above allegations are unsubstantiated but if any additional information is received this complaint can be amended and findings can be changed. Per California Code Regulation, Title 22, Division 6, Chapters 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) 4, there are no deficiencies to be cited at this time. Exit interview was conducted and the copy of the report will be emailed to the licensee for signature

Investigation Findings:
13On December 7, 2021 at 11:21 am, Licensing Program Analyst (LPA) Enrique Hernandez made an Unannounced phone call to the above facility for the purpose of concluding the investigation on the above allegations and to deliver the findings. LPA spoke with the Licensee Sally Cook, and together discuss the findings. On July 15, 2020, the Department received a complaint alleging Facility staff did not allow resident to do laundry and Facility staff locked resident out of facility. Confidential interviews were conducted with three (3) staff and seven (7) clients. Facility staff did not allow resident to do laundry Confidential interviews revealed that clients are allowed to do their laundry, but not during school hours. It was also revealed during the investigation that the facility did not have a laundry schedule, but after this incident, the facility put in place a laundry schedule so that clients would not do laundry during school hours. Continue on LIC9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: VISIT DATE: 12/07/2021

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

announced_status: Unannounced


raw_content:
Investigation Findings:
13This is an amended report from January 9, 2022 at 10: AM. Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted an unannounced complaint inspection for the purpose of delivering findings and met with Trina Garcia, Direct Care Staff. The report was amended to provide additional information regarding the complaint finding. During the investigation process, AGPA Woodard was unable to interview the staff who is the alleged perpetrator. The alleged perpetrator no longer works at the facility, and contact information is no longer valid. In interviews it was reported that staff was seen on the couch masturbating, and when seen, she stopped. In other interviews it was stated that a special incident report was written as well as an in-house investigation that was conducted by Facility Administrator. It was reported that a conversation was held with staff (alleged perpetrator) and staff denied it and stated she would never do anything like that; however client interviews were not conducted. AGPA requested a copy of the SIR and the in-house investigation, however after several requests, was never provided to AGPA. Based on confidential interviews with 12 staff members and four youth, AGPA Woodard determined that the allegation is unsubstantiated. An unsubstantiated finding means although the allegation may have happened, the preponderance of evidence does not prove it. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard 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 2

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


raw_content:
Narrative:
The Department has decided that the allegation of Neglect Lack of Supervision is unsubstantiated, but if any additional information is received this complaint can be amended and findings can be changed. Per California Code Regulation, Title 22, Division 6, Chapters 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), there are no deficiencies to be cited at this time. A copy of this report will be emailed to the facility administrator, due to technical difficulties with the printer

Investigation Findings:
13On January 27, 2022, 8:30am, Licensing Program Analyst (LPA) Enrique Hernandez made an unannounced visit to the above facility for the purpose of concluding the investigation on the above allegation and to deliver the findings. LPA met with David Haper Facility Administrator (FA), and together discussed the investigative findings. On July 29, 2020, the Department received a complaint alleging Staff are not meeting minor's medical needs During the confidential interviews and documentation obtained, the facility did not bring the medication to the client after picking it up and waited until the next day to bring it to the facility. Based on all of the interviews conducted, the Department has concluded the above allegation violation to be Substantiated, meaning that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code Regulation, Title 22, Division 6, Chapters 5, General Licensing Regulations, the following deficiency has been cited. (See LIC9099-D). A copy of this report will be emailed to the facility administrator, due to technical difficulties with the printer SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: 425802135

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

met_with: Administrator


raw_content:
Narrative:
Many of the interviewers said that even though there were bugs at the facility a few months ago, the facility went to great lengths to accommodate the client's needs and keep them safe by calling the pest control and taking them to the hospital for skin rash treatment. Staff said the facility offers them all the training and support they need. During interviews with clients and staff, it was stated that there is always five-gallon jug of water in each cottage. During the interviews with the clients and staff said that they feel safe in the facility because staff are always supervising clients. During the confidential interviews it was revealed that the clients files are all complete. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. The Department has decided that the above allegations are unsubstantiated, but if any additional information is received this complaint can be amended and findings can be changed. Per California Code Regulation, Title 22, Division 6, Chapters 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), there are no deficiencies to be cited at this time. A copy of this report will be emailed to licensee for signature

Investigation Findings:
13On March 7, 2022, at 12:00pm, Licensing Program Analyst (LPA) Enrique Hernandez made an unannounced telephone call the above facility for the purpose of concluding the investigation on the above allegations and deliver the findings. LPA spoke with David Harper Facility Administrator (FA), and together discussed the investigative findings. On 09/04/2020 the Department received a complaint with the following allegations Facility is in disrepair, drinking water is not available for the youth in care, Facility food service is inadequate, Facility has insects, Facility is unsanitary, Staff are not properly trained and Minor's files are incomplete. During the complaint investigation of the above allegations, there were no consistent statements to substantiate the allegations. the clients of the facility said that while there are things that need to be repair and cleaned at the facility, the facility takes care of repairing and cleaning the facility right away. Confidential interviews with the clients also said that they give them food, but it depends on the cook and sometimes they don't like what they make them to eat but they always get their three meals a day. Continue on LIC9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: VISIT DATE: 03/07/2022

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

met_with: Facility Administrator


raw_content:
Narrative:
Facility has pests Confidential interviews revealed that they hear animal noises in the middle of the night, due to the facility's remote location, but there was no confirmation of seeing rats in the facility. The facility has called pest control and they have put traps in the facility to prevent rats from entering the facility. Facility staff failed to ensure that group home minors participate in distance learning Confidential interviews revealed that the facility is providing distance learning for the clients, with the exception of some statements saying that completing packages and having school via Zoom is not the same as attending in person. Lack of supervision resulted in group home minor being trafficked by another minor in the home and Facility Confidential interviews revealed that facility staff always supervise clients. Some interviews revealed that there have been problems between clients, such as fights, but the staff is there to try to prevent anyone from getting hurt. During the investigation and the interviews conducted, nothing was revealed about the trafficking of minors in the facility. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. The Department has decided that the allegations are unsubstantiated but if any additional information is received this complaint can be amended and finding can be changed. PER California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), Chapter 7. Version 4.0, there are no deficiencies to be cited at this time. A copy of this report will be emailed to the administrator for signature

Investigation Findings:
13On April 4, 2022, at 11:30am, Licensing Program Analyst (LPA) Enrique Hernandez made an unannounced telephone call the above facility for the purpose of concluding the investigation on the above allegations and deliver the findings. LPA spoke with David Harper Facility Administrator (FA), and together discussed the investigative findings. On November 12, 2020, the Department received a complaint alleging Group home minors are not being adequately fed, Facility has pests, Facility staff failed to ensure that group home minors participate in distance learning and Lack of supervision resulted in group home minor being trafficked by another minor in the home. Confidential interviews were conducted, and the following information was obtained during the course of the investigation: Group home minors are not being adequately During confidential interviews with staff and clients, there were conflicting statements about the food. Even though they don't like how one of the chefs' cooks, interviews revealed that the facility always provides food for all clients. Continue on LIC9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: VISIT DATE: 04/04/2022

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


raw_content:
Narrative:
Based on the confidential interviews, observation, and record review, it has been determined that although the allegation Minor's personal rights were violated, may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. A copy of this report will be emailed to licensee for signature

Investigation Findings:
13On April 27, 2022, at 3:30pm, Licensing Program Analyst (LPA) Enrique Hernandez made an unannounced phone call to former licensee Sally Cook due to facility closure. The purpose of the call is to deliver the findings on the above allegation. LPA spoke with Sally Cook and discussed the investigative findings. On March 23, 2021, the Department received a complaint alleging: Minor's personal rights were violated. During the investigation process, confidential interviews conducted with staff and clients confirmed that religious services are indeed offered at the facility, they also confirmed that no one has to participate in them if they wish to do so. Some confidential interviews said that if they do not participate in religious activities they lose points, to which other interviews said that points are not deducted for not participating in any religious services. Other confidential interviews said they had to go to church on Christmas Eve, but other interviews said that if they didn't want to go to church, they didn't have to attend and could stay at the facility if they wanted to. Continue on LIC9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: VISIT DATE: 04/27/2022

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


raw_content:
Narrative:
Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. The Department has decided that the allegations are unsubstantiated, but if any additional information is received this complaint can be amended and finding can be changed. PER California Code Regulation, TITLE 22, DIVISION 6, CHAPTERS 1, General Licensing Regulations, and Short Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS), Chapter 7. Version 4.0, there are no deficiencies to be cited at this time. A copy of this report will be emailed to licensee for signature

Investigation Findings:
13On April 27, 2022, at 3:30pm, Licensing Program Analyst (LPA) Enrique Hernandez made an unannounced phone call to former licensee Sally Cook due to facility closure. The purpose of the call is to deliver the findings on the above allegations. LPA spoke with Sally Cook and together discussed the investigative findings. On February 19, 2021, the Department received a complaint alleging Facility staff did not prevent youth from engaging in CSEC activities and Facility staff are not allowing youth to be interviewed by medical provider. During confidential interviews with staff and clients, there was no corroboration of the above allegations. Although some of the confidential interviews indicated that the facility did not allow the medical provider to interview the client, this allegation was not substantiated because during the confidential interviews with clients and staff that all clients go to their medical appointments, and they can speak with their medical provider whenever they need to. In addition, confidential interviews confirmed that facility staff is constantly supervising the clients in the facility, and the interviews produced no evidence of a client recruiting clients to engage in CSEC activities in the facility. Continue on LIC9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: VISIT DATE: 04/27/2022

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

met_with: Called Sally Cook


raw_content:
Investigation Findings:
13On April 27, 2022, at 3:30pm, Licensing Program Analyst (LPA) Enrique Hernandez made an unannounced phone call to former licensee Sally Cook due to facility closure. The purpose of the call is to deliver the findings on the above allegations. LPA spoke with Sally Cook and discussed the investigative findings. On March 16, 2021, the Department received a complaint alleging: Staff did not provide an appropriate sleeping arrangement for minors while in care During the investigation process it was confirmed that all clients have their own bed in the cottage. Although two clients lay in the same bed for a while, C2 said the staff constantly told them to get out of bed and the staff did not move until the clients got up. In addition, confidential interviews revealed that they are constantly supervised by staff. Based on the confidential interviews, observation, and record review, it has been determined that although the allegation Minor's personal rights were violated, may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. A copy of this report will be emailed to licensee for signature UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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


raw_content:
Narrative:
On January 18, 2022, CCLD received a complaint allegation in reference to the same reported incident concerning conduct inimical by S1 towards C1 and C2. On January 27, 2022, LPA E. Hernandez, conducted the initial complaint inspection to initiate the investigation and obtained associated documentation from facility and client files. Investigator Zertuche reviewed facility and client records, conducted confidential interviews and completed physical observations. The investigation revealed on one night in December 2021, S1 transported C1 and C2 to S1's place of residence without the knowledge or instruction of facility administration. It was reported that S1 provided C1 and C2 with alcohol, while at the residence. S1 denied providing C1 and C2 with alcohol; however, S1 admitted to stopping by S1's residence while transporting C1 and C2. Based on confidential interviews and corroborating evidence the preponderance of the evidence standard has been met. Information obtained remained consistent to prove S1 provided alcohol to minors, C1 and C2 while in care. The allegation is deemed substantiated which poses an immediate health, safety and personal rights risk of harm to children placed in care. The following deficiency is cited in accordance with Title Division 6, Health and Safety Code 1550 (see page 9099-D). An exit interview was conducted. A copy of this report, the Confidential Names List and appeal rights were provided via email to Facility Representative, Sally Cook for signature. A copy of this report will also be provided through US Mail.

Investigation Findings:
13On September 13, 2022 at 2: PM Regina Martin, Licensing Program Analyst (LPA) spoke with Facility Representative, Sally Cook for the purpose of discussing and delivering the above-mentioned complaint investigation finding. The investigation was conducted by Community Care Licensing Division (CCLD) Investigator, Peter Zertuche. On January 14, 2022, CCLD received a call from Hope Refuge Facility Administrator to report in part, an incident that a staff member (Staff Member #1-S1) had taken Client #1 (C1) and Client #2 (C2) to staff's personal residence and provided them with alcohol [see LIC811, dated 9/13/2022]. Upon receipt of reported claim, facility administration instructed S1 to leave the facility premises pending their investigation. (Continued on page LIC9099-C) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Regina Martin 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 34-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, N. Continental Blvd. #290B FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: VISIT DATE: 09/13/2022

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


raw_content:
Narrative:
Based on the confidential interviews, observation, and record review, it has been determined that although the allegations, may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. A copy of this report will be emailed to licensee for signature

Investigation Findings:
13On November 15, 2022, at 3:45 pm, Licensing Program Analyst (LPA) Enrique Hernandez made an unannounced phone call to former licensee, Sally Cook due to facility closure. The purpose of the call is to deliver the findings of the complaint the Department received on On May 3, 2021, alleging: Lack of supervision resulting in minors engaging in physical altercation and Staff failed to protect minor's personal belongings. During the investigation process, confidential interviews were conducted with the staff and clients of the facility. It was verified that there was a physical altercation between the clients of the facility. Interviews also confirmed that staff went to great lengths to ensure the clients were safe during altercations by redirecting the clients to stop fighting. As for staff who failed to protect clients' personal belongings, confidential interviews said they were not aware of any clients taking other clients' personal belongings. An additional interview said that the staff was never informed that someone had stolen the client's personal belongings. Continue on LIC9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: VISIT DATE: 11/15/2022


raw_content:
Narrative:
Records reviewed indicates Y1 resided in the facility from April 13, 2021 through January 28, 2022. Confidential statements obtained found no knowledge, witnesses or evidence of said incident. Youth #1 did not disclose any sexual abuse to any staff members, residents or local Sheriff's office. Attempts to interview Youth #1 were unsuccessful during the investigation process. Based on confidential statements and documentary evidence, the preponderance of the evidence standard has not been met, therefore the allegation is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. There are no deficiencies cited at this time. A copy of this report was emailed to Facility Representative, Sally Cook for signature.

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

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


raw_content:
Narrative:
Based on the confidential interviews, observation, and record review, it has been determined that although the allegation, may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. A copy of this report will be emailed to licensee for signature

Investigation Findings:
13On January 12, 2023, at 12:45 pm, Licensing Program Analyst (LPA) Enrique Hernandez made an unannounced phone call to the former licensee, Sally Cook, due to facility closure. The purpose of the call is to deliver the findings of the complaint the Department received On January 5, 2022, alleging: Staff do not ensure the minors are consuming the appropriate amount of fluids while in care. On January 9, 2022, AGPA conducted a tour of the cottage and observed two 10-gallon orange water coolers of filtered water provided to the clients. During the confidential interviews, S1 and C1 stated that the clients didn't like the taste of the water from the 10-gallon orange water cooler. On 04/30/2021, during the LPA Hernandez inspection, clients informed LPA Hernandez that they did not like the taste of the water from the orange water coolers. LPA noted the orange cooler spout was dirty at the inspection time and cited the facility. Continue on LIC9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: VISIT DATE: 01/12/2023


raw_content:
Narrative:
Based on the confidential interviews, observation, and record review, it has been determined that although the allegation, may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. A copy of this report will be emailed to the licensee for signature

Investigation Findings:
13On January 12, 2023, at 12:45 pm, Licensing Program Analyst (LPA) Enrique Hernandez made an unannounced phone call to the former licensee, Sally Cook, due to facility closure. The purpose of the call is to deliver the findings of the complaint the Department received On August 6, 2021, alleging Staff did not prevent the youth from AWOL's, Failure to safeguard the resident's personal belongings, and the facility did not maintain accurate resident records. Confidential interviews with staff and the client's staff did not corroborate the allegations mentioned in this report. The clients said that no one had stolen their belongings, and they had not heard of anyone having their belongings stolen. The staff confirmed that no clients have told them of anyone stealing their items. Other interviews also said that when the client's AWOL from the facility, staff follows them until they are out of sight, which is when they contact law enforcement. On 8/21/2021, AGPA Barnes received copies of all resident records, and no concerns were informed. Continue on LIC 9099-C. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: VISIT DATE: 01/12/2023

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


raw_content:
Narrative:
Based on the confidential interviews, observation, and record review, it has been determined that although the allegation, may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. A copy of this report will be emailed to the licensee for signature

Investigation Findings:
13On January 12, 2023, at 12:45 pm, Licensing Program Analyst (LPA) Enrique Hernandez made an unannounced phone call to the former licensee, Sally Cook, due to facility closure. The purpose of the call is to deliver the findings of the complaint the Department received On 08/26/2021 alleging: Staff member sexually abused a youth in care, Group home youth stabbed other youth in the home, and Saff did not intervene during incidents between youths in the home. Confidential interviews with staff and clients did not substantiate the allegations made in this report. During client interviews, there were conflicting statements, and staff denied the allegations in this report. Facility staff stated they intervene when a physical fight starts or even before it starts; facility staff redirects the clients to other activities. Some of the clients confirmed that the staff intervenes when an altercation between the clients begins. Regarding the sexual abuse, there were conflicting statements, one of the clients does not remember the staff's name or the client who touched C1 inappropriately, and no other client confirmed the incident. Regarding the stabbing, they were also contradictory statements. Facility staff stated that no clients had come forward to inform them of any sexual abuse or clients being stabbed. Continue on LIC UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: HOPE REFUGE, INCFACILITY NUMBER: VISIT DATE: 01/12/2023

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


raw_content:
Investigation Findings:
13On March 21, 2023, at 3:30pm, Licensing Program Analyst (LPA) Enrique Hernandez made an unannounced phone call to the former licensee, Sally Cook, due to facility closure. The purpose of the call is to deliver the findings of the complaint the Department received On 02/10/2022 alleging: Staff had possession of marijuana and alcohol at facility. During confidential interviews with the relevant parties to the complaint, there were conflicting statements to substantiate the accusation. Although there was a statement confirming the allegation, no one else could corroborate the allegation. The facility staff denied knowing that S2 was bringing alcohol or marijuana onto the premises. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. The Department has decided that the allegation is unsubstantiated. If additional information is received, this complaint can be amended, and the findings can be changed. A copy of this report will be emailed to the licensee for signature. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

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