summary: Facility Evaluation

raw_content:
Narrative:
On December 21, 2023 @ 9: AM Licensing Program Analyst (LPA) Zena Phillips & Licensing Program Manager (LPM) Lakescia Smith made an announced visit to WAYFINDER FAMILY SERVICES - THE HAVEN for the purpose of conducting Pre-Licensing visit. LPA Phillips and LPM Smith were greeted by Jasmine Griffis/Program Director, Cecilia Blanco/Assistant Director for Group Homes, & Edith Mejia /Assistant Director of Supportive Services who granted access to the facility. There are currently no children placed in the facility. LPA Phillips & LPM Smith toured entire facility. The program will provide care and supervision for children ages 12- 17 1/2 years old males ambulatory only.The facility has a main lobby on the ground floor with two staff offices to the right of the entrance. There is a camera in the upper right corner of the wall facing the entrance. To the left of entrance door is a common living area equipped with three cushion sofa, two cushion sofa and large one cushion chair facing wall mounted television. There is a bookshelf with many books for reading. The room has long dining table with benches with adequate seating for twelve. The hallway has seven offices to be used as computer lab, education specialist office, two case manager. There are two isolation rooms with twin bed,two drawers attached under bed, clean linen, hygiene products, six drawer dresser. The two rooms have double door closet with adequate storage space for personal items. The two rooms share Jack & Jill bathroom with double sink, LPA Phillips observed one wall mounted fire extinguisher fully charged. There is an exit door at the other end of the hall way with camera just above door. The kitchen has four burner stove and LPA Phillips confirmed only two burners ignite, upper cabinets on left have bowls, plates, cups and additional food storage containers. Drawer to the left of the stove has spoons and forks. Drawer to the right of the stove has large serving spoons, spatula and necessary cooling utensils. cont on 809c Sharps and knives are stored in locked box housed in staff office near entrance. Lower cabinets on left side have large storage and serving containers. LPA Phillips observed dishwasher on the left side between lower cabinets. LPA Phillips observed no storage of cleaning or chemicals under the kitchen sink. There is refrigerator with upper freezer, no food in fridge at this time. LPA Phillips observed in the kitchen on left wall mounted fire extinguisher fully charged. LPA Phillips observed outside kitchen the following posted on bulletin board sample menu posted, proper food handling posters, and scheduled meal times. There is an additional bulletin board with same recipes. Down stairs is laundry room with working washer and dryer, door has locked. There are six bedrooms all located on the right side of the hallway. The rooms are equipped with two twin bed and two drawers attached to bed frame. LPA Phillips observed six dresser drawer, desk with one chair and upper cabinets above desk for storage in each room. The beds each have mattress, clean linens, pillows and appears in good condition. The windows have alarms that sound when window is opened. The bathroom door has a sensor that alerts staff when door is opened. The bathrooms are Jack and Jill with shower, double sink and toilet. Hot water was tested and found to be between 105-120 degrees (F). LPA Phillips and LPM Smith observed bedroom window only partially opened due to installed bracket stopper. All the bedrooms are equipped with carbon monoxide combo smoke alarm. LPA Phillips and LPM Smith requested smoke alarm test and confirmed alarms working. The bedrooms each have speaker system for communication when smoke alarm is triggered. LPA Phillips and LPM Smith observed on each bed back with hygiene products, such as shampoo, deodorant, toothpaste, toothbrush and comb. LPA Phillips and LPM Smith observed personal right posted in the hallway downstairs outside the sleeping quarters. The left side of the downstairs hallway has third wall mounted fire extinguisher fully charged. LPA Phillips and LPM Smith observed camera at end of hallway outside first bedroom. LPA Phillips requested to see camera view from IT department and viewed camera angels. LPA Phillips observed all private spaces have no camera view. LPA Phillips and LPA Smith observed hallway has closet for cleaning supply storage and boiler room with new copper pipes. cont on 809c LPA Phillips and LPM Smith observed one landline in Green Room pre programmed for hotline calls for PSA compliance. LPA Phillips was advised will have one cell phone per shift for residents to make personal calls. LPA Phillips and LPM Smith advised to have perishable and non-perishable foods for more than a one (1) week supply. Facility will have hot meal brought over from main campus kitchen. LPA Phillips and LPM Smith observed the facility gymnasium and gated swimming pool area. LPA & LPM observed the facility to have adequate indoor and outdoor activity space. The yards were inspected and found to be clean and free of debris and observable hazards. First aid kit located in staff office area fully stocked with thermometer, tweezer, gauze, scissors and first aide guide. Facility has nurse's station on campus. Caregiver(s)/adults working/residing in the facility must have DOJ/FBI criminal record clearances and Child Abuse Index Checks. Emergency Mass Disaster Plan was posted in main entrance at top of stairs. LPA Phillips and LPM Smith reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. The facility will operate within the capacity and limitations of the license. LPA Phillips and LPM Smith discussed alarms on bathroom doors and advised will require further review. Perishable and non-perishable food will be supplied prior to resident move-in. LPA follow up: Two burner on stove failed to ignite when handled turned to ignite. Faucet in second bedroom Jack and Jill bathroom on left side was loose and not securely mounted. LPM Smith advised facility to post emergency exit sign on downstairs exit door due to exit not for regular use. Windows in all bedrooms require removal of stopper bracket to allow window to completely open. Cabinet in bedroom above desk has missing door and was advised work order was placed to replace door. Exit Interview was conducted, and a copy of this report will be emailed to Jasmine Griffis /Program Director and Tony Weaver.

met_with: Jasmine Griffis/Program Director


state: CA

facility_name: WAYFINDER FAMILY SERVICES - THE HAVEN

summary: Facility Evaluation

raw_content:
Narrative:
On 01/16/ Licensing Program Analyst (LPA) Zena Phillips met with Tony Weaver/VP of Clinical Housing Services, Veta Talton/Administrator, Jasmine Griffis/ Program Director to complete Component III. LPA requested Orientation Certificate and valid driver's license and both were provided to LPA. LPA discussed the following reporting requirement with attendees: Children's Records:LIC Preplacement Appraisal Information , LIC Appraisal /Needs and Services Plan, LIC Identification and Emergency Information, LIC 605A Release of Client /Resident Medical Information, LIC Current Admission Agreement with authorized signature, LIC 613B Personal Rights, LIC Unusual Incident /Injury Report Personnel Records: LIC 500, LIC Health Screening, LIC Criminal Record Statement, LIC Statement Acknowledging Requirements to Report Suspected Child Abuse, to be maintained by the facility. LPA discussed wand and was advised by Tony Weaver that staff use cellphone scan a barcode to the right of each door to electronically confirm room checks are completed. LPA advised Tony to submit waiver for bathroom door alarms. LPA will conduct follow up visit to the facility to complete pre licensing inspection to confirm corrections have been made. LPA advised Program Statement is still under review. Exit interview was conducted and reported will be provided to Tony Weaver & Jasmine Griffis.

report_type: Facility Evaluation


summary: Facility Evaluation

raw_content:
Narrative:
On January 16,2024 @ 2:15PM Licensing Program Analyst (LPA) Zena Phillips made an announced follow up visit for the purpose of completing Pre Licensing Inspection visit to the facility listed above. LPA Phillips was greeted by Tony Weaver/ VP of Clinical Housing Services who granted access to the facility. There are currently no children placed in the facility.LPA toured the entire facility. LPA observed Foster youth bill of rights and grievance procedures were posted in hallway of the facility. LPA observed the following corrections have been made: The facility has a main lobby and directly facing the front entrance is a newly assigned file office. LPA Phillips observed the following two (2) large files cabinets with four (4) drawers, desk with two (2) computer monitors. A small wall desk with table and upper cabinet storage. The kitchen has brand new five (5) burner stove and LPA Phillips confirmed all burners ignite, upper cabinets on left are fully stocked with non perishable food. LPA Phillips observed, fruits cups, granola bars, large cans of corn & green beans along with multiple cases of water. LPA Phillips observed adequate non perishable food clearly labeled. LPA observed the following in downstairs bathroom door locks from the interior on both sides. LPA confirmed windows fully open without obstruction as required. The bathroom faucet has been secured to sink. LPA observed adequate hygiene products in bathroom, additional towels and bed linens for client use. LPA observed closet with adequate robes, jogging set and sandals. LPA observed the facility to be clean safe, sanitary and license ready. Exit Interview was conducted, and a copy of this report will be emailed to the Senior Clinical Director

visit_type: Prelicensing

met_with: Tony Weaver/VP of Clinical Housing Services


summary: Facility Evaluation

raw_content:
Narrative:
On May 7, 2024 @ 9:00AM Licensing Program Analyst (LPA) Zena Phillips made an unannounced visit to WAYFINDER FAMILY SERVICES - THE HAVEN for the purpose of conducting Case Management Post-Licensing visit. LPA Phillips was greeted by: Jasmine Griffis/Program Director who granted access to the facility. There are currently 5 clients placed in the facility. LPA requested LIC 500, client roster and both were provided. The program provides care and supervision for children ages 12-17 1/2 years old males ambulatory only. The facility has a main lobby on the ground floor with two staff offices to the right of the entrance. There is a camera in the upper right corner of the wall facing the entrance. To the left of entrance door is a common living area equipped with a three cushion sofa, two cushion sofa and large one cushion chair facing wall mounted television. There is a bookshelf with adequate books for reading. The room has two (2) long dining table with benches with adequate seating for twelve. The hallway has seven (7) offices, computer lab with six (6) computers and nine (9) chairs, spare office with desk, two (2) file cabinets, closet has additional linen supplies and hygiene products. There are two isolation rooms with twin bed, two drawers attached under bed, clean linen, hygiene products, six drawer dresser. The two rooms have double door closet with adequate storage space for personal items. The two rooms share Jack & Jill bathroom with double sink, LPA observed one wall mounted fire extinguisher fully charged. There is an exit door at the end of the hallway with camera just above door. The kitchen has four burner stove and LPA confirmed all burners self ignite, upper cabinets on left have bowls, plates, cups and additional food storage containers. Drawer to the left of the stove has spoons and forks. Drawer to the right of the stove has large serving spoons, spatula, and necessary cooking utensils. cont on 809c Sharps and knives are stored in locked box housed in staff office near entrance. Lower cabinets on left side have large storage and serving containers. LPA observed dishwasher on the left side between lower cabinets. LPA observed no storage of cleaning or chemicals under the kitchen sink. There is refrigerator with upper freezer with frozen veggies, meat, and additional frozen foods. The refrigerator contained,milk, cheese, juice, condiments and eggs. LPA observed adequate fresh fruit on the counter. LPA observed additional food storage in the pantry cabinets to the right of the refrigerator. LPA observed in the kitchen on left wall mounted fire extinguisher fully charged. LPA observed perishable and non-perishable foods for more than a one (1) week supply. Facility will have hot meal brought over from main campus kitchen. LPA observed outside kitchen the following posted on bulletin board sample menu posted, proper food handling posters, and scheduled mealtimes. There is an additional bulletin board with food recipes. Downstairs is laundry room with working washer and dryer, door has locked. There are six bedrooms all located on the right side of the hallway. The rooms are equipped with two twin bed and two drawers attached to bed frame. LPA observed six dresser drawers, desk with one chair and upper cabinets above desk for storage in each room. The beds each have mattress, clean linens, pillows and appears in good condition. The windows have alarms that sound when window is opened. The bathroom door has a sensor that alerts staff when door is opened. The bathrooms are Jack and Jill with shower, double sink and toilet. Hot water was tested and found to be between 105-120 degrees (F). LPA and observed bedroom window with intact screen. All the bedrooms are equipped with carbon monoxide combo smoke alarm. LPA requested smoke alarm test and confirmed alarms working. The bedrooms each have speaker system for communication when smoke alarm is triggered. LPA observed adequate hygiene products, such as shampoo, deodorant, toothpaste, toothbrush, and comb. cont on 809c LPA observed personal right posted in the hallway downstairs outside the sleeping quarters. The left side of the downstairs hallway has third wall mounted fire extinguisher fully charged. LPA observed camera at end of hallway outside first bedroom. LPA observed all private spaces have no camera view. LPA observed hallway has closet for cleaning supply storage and boiler room with new copper pipes. LPA observed camera in therapy room with and advised by staff no audio just video image. LPA observed one landline in Green Room pre programmed for hotline calls for PSA compliance. LPA confirmed staff have DOJ/FBI criminal record clearances and Child Abuse Index Checks. Emergency Mass Disaster Plan was posted in main entrance at top of stairs. All posting requirements were met. LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. The facility is operating within the capacity and limitations of the license. During today;s inspection LPA conducted three (3)Staff interviews and three (3) Client interview. LPA will return at a later date to review staff and client files. Exit Interview was conducted, and a copy of this report will be emailed to Jasmine Griffis /Program Director, Cecilia Blanco/ Assistant Director, and Tony Weaver.

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On May 15, 2024 @ 9: AM Licensing Program Analyst (LPA) Zena Phillips made an unannounced visit to WAYFINDER FAMILY SERVICES - THE HAVEN for the purpose of continuing Case Management Post-Licensing visit. LPA Phillips was met by Cecilia Blanco/Assistant Director who granted access. There are currently 6 clients placed in the facility. There are no weapons in the facility. LPA reviewed the following records during the inspection: Client Records: The program currently has a total of six (6) clients. LPA reviewed five (5) client records and found each record to meet required regulations. Staff Records: LPA reviewed a total of five (5) staff records and confirmed files contained staff qualifications, current CPR/First Aid cards, health screening, and TB test results. LPA obtained the LIC 500 to verify Staff to Client ratio. LPA reviewed the Facility Profile and Personnel Report and confirmed that personnel have required criminal record clearance: DOJ, FBI and Child Abuse; which meet qualification. This inspection included an overview of required Core Services and Supports and based upon inspection of facility records and interviews of staff and clients. Licensee is meeting all requirements. Transportation: The facility has a total of 2 vehicles to transport clients. LPA inspected 1 out of 2 vehicles and found seat belts and horns in working order, travel first aid kits, and current registration and insurance. Vehicles are insured by Nonprofit Insurance Alliance of CA and insurance card was valid at time of inspection. LPA observed 1 of 2 "To Go Bag" taken by staff on all outings. LPA observed, first aid kit, sunscreen, bug spray, client roster, emergency procedure protocol. cont on 809c Additionally, the facility has a nursing center, a gym, an a locked/gated swimming pool, which meets licensing requirements, on the premises. All exits are free of hazards and all doors open freely. The facility operates within license conditions and limitations including capacity limitations. LPA discussed and advised the Licensee to ensure the following: Children are supported and encouraged to participate in extracurricular activities. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. All posting requirements and Emergency Plan were met. This inspection included an overview of required Core Services and Supports and based upon inspection of facility records and interviews of staff and clients. Licensee is meeting all requirements. LPA observed the facility to be clean safe, and sanitary. There were no deficiencies cited per California Code of Regulations and Interim Licensing Standards. Exit interview was completed and a copy of this report will be provided to Cecilia Blanco & Edith Mejia.

met_with: Cecilia Blanco/Assistant Director


summary: Facility Evaluation

raw_content:
Narrative:
On March 6, Licensing Program Analyst (LPA) C. White made an unannounced visit to Wayfinder Faimly Services - The Haven for the purpose of conducting Annual/Required inspection. LPA met with Assistant Director, Cecilia Blanco and Quality Assurance Specialist, Cinthya Lopez and was granted access to the facility. There are currently 8 clients placed in the facility. LPA requested LIC 500, client roster and both were provided. The program provides care and supervision for children ages 12-17 years old males ambulatory only. The facility has a main lobby on the ground floor with two staff offices to the right of the entrance. There is a camera in the upper right corner of the wall facing the entrance. To the left of entrance door is a common living area equipped with three (3) sofas, and a wall mounted television. The room has two (2) long dining table with benches with adequate seating. The main floor has seven (7) offices, a computer lab with six (6) computers and desk. There are two (2) rooms with a twin bed, for clients who get sick. The two rooms share Jack & Jill bathroom with double sink, LPA observed one wall mounted fire extinguisher fully charged. There is an exit door at the end of the hallway with camera just above door. The kitchen has five burner gas stove, and all burners were operational at the time of the inspection. Cabinets contained bowls, plates, cups and additional food storage containers. Drawers contained spoons, forks, and cooking utensils. Sharps and knives are stored in locked box housed in staff office near entrance. LPA observed a dishwasher, toaster, microwave, a refrigerator with top freezer. LPA observed adequate fresh fruit on the counter. LPA observed additional food storage in the pantry. LPA observed a wall mounted fire extinguisher fully charged. LPA observed perishable and non-perishable foods for more than a one (1) week supply. Facility has hot meals brought over from main campus kitchen Monday through Friday. LPA observed a bulletin board just outside kitchen with menu posted. The bottom floor has a laundry room with working washers and dryers. LPA observed cleaning supplies storage in this room and the door remains locked. There are six bedrooms all located on the right side of the hallway. The rooms are equipped with two twin bed and two drawers attached to bed frame. LPA observed six dresser drawers, desk with one chair and upper cabinets above desk for storage in each room. Report continued on LIC 809C (Page 1 of 2) The beds each have mattress, clean linens, pillows and appears in good condition. The windows have alarms that sound when window is opened. LPA and observed bedroom window screen to be clean and free of debris. The bathrooms are Jack and Jill with shower, double sink and toilet. Hot water was tested and found to be between 105-120 degrees (F). All the bedrooms are equipped with carbon monoxide combo smoke alarm. LPA requested smoke alarm test and confirmed alarms working. The bedrooms each have speaker system for communication when smoke alarm is triggered. LPA observed personal right posted in the hallway downstairs outside the sleeping quarters. The left side of the downstairs hallway has third wall mounted fire extinguisher fully charged. LPA observed camera at end of hallway outside first bedroom. LPA observed all private spaces have no camera view. LPA observed one landline in PSA room. The facility has a nursing center, a gym, an a locked/gated swimming pool, which meets licensing requirements, on the premises. All exits are free of hazards and all doors open freely. LPA confirmed staff have DOJ/FBI criminal record clearances and Child Abuse Index Checks. Emergency Mass Disaster Plan was posted in main entrance at top of stairs. All posting requirements were met. The facility operates within license conditions and limitations including capacity limitations. LPA discussed and advised the Licensee to ensure the following: Children are supported and encouraged to participate in extracurricular activities. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. All posting requirements and Emergency Plan were met. LPA will return at a later date to conduct interviews and review staff and client files. All clients were at school during the inspection. An Exit Interview was conducted, and a copy of this report will be emailed to Assistant Director Cecilia Blanco. (Page 2 of 2)

visit_type: Annual


facility_name: WE THRIVE AND SUCCEED

summary: Facility Evaluation

raw_content:
Narrative:
On January 23, 2023, Licensing Program Analyst (LPA) and Licensing Program Manager (LPM), Jennifer Smith met with Applicant, Kedra Creer, via Microsoft Teams for a Component II Interview. LPA and LPM went over revisions needed for the Application and Program Statement. The following documents and sections are needed for revision and/or updates: LIC Application Documents Needed - Age range of clients - please ensure to correct and specify the range of age throughout the LIC200 (add non-minor dependents to section #4 other) and the Program Statement - LIC401 - please provide original per checklist page 2 - form appears to be a copy - LIC402 - please provide original with seal - LIC 610- VI is blank add the location of the first aid kit - Lease agreement does not state when the term expires Program Statement Documents Needed/Correct Section 3 -Purpose, Methods, Goals o Days and hours of operation o Description of optional services o Procedures for medical emergencies. (Pg 61 can be moved to his section.) o Community resources and consultants to be used Section 4 -Planned Activities/Use of Community Resources o Plan of activities (monthly schedule for indoor and outdoor activities o Plan for individual child and group interaction activities o Social, education, and recreation activity schedule Section 8- Admission/Intake o Age range needs to be consistent (6-14, 10-14, non-minor dependent) o How is compatibility determined o Client's rights/personal rights o Pre-admission appraisal plan for clients that are not non-minor dependents needed. o Sign in-sign out procedures o Personal Rights of Clients (process of informing clients of their rights, providing copies to responsible parties/placements/families) Incomplete o Licensing Agency Rights (included on Program Admission Agreement located on pg 75) Section 9- Needs & Services Plans/Assessment, what is ID Team? o How will the facility ensure that client's voice is heard? o Procedures for reviewing and evaluating needs & services. (how often and what happens when it is identified that a change is needed) Section 10- Discharges/Removal o Polices & Procedures being provided to Children & Authorized Representative(s) o Signed Polices & Procedures maintained in the child's record. o Written Removal/Discharge Record developed & Maintained by Social Work Staff Section 11- Visitation Rules & Policy o How will provider ensure successful communication with family, friends and others involved in client's life. Pg 88 be more specific. Section 12- House Rules o Dating other children in placement o Completing Homework (engaging in tutoring) o Chores and cleaning of own personal space (bedroom) o Use of electronic devices (times when not permitted) o Reasonable and Prudent Parent Standard Application Section 5- Special Services/Programs offered o Other Special Services or Programs that could be offered based on clientele to be served. Can individuals ask for special services/programs? Explain that process. Section 6-Medical/Dental o Medical, psychiatric and psychological reports that identify special needs of children diagnosed as mentally disordered or developmentally disabled o Medical and dental insurance coverage information, or information regarding the agency or person responsible for medical and dental costs. o Consent forms, completed by the child's authorized representative(s), to permit the facility to authorize medical care. (provide copy). o Procedures for identifying/handling medical, dental and psychiatric emergencies. o A copy of the standard appraisal form specified in Section 84068.1(b)(1)(C), if used o A copy of the current order, or written authorization of the child's parent or guardian, for each psychotropic medication, as defined in Section 84001(p)(4). (Add JV220) o Written authorization of the child's parent or guardian may only be documented in lieu of a court order if the child is not a dependent or ward of the court, or it is documented in the child's record that the county placing agency has verified a court order is not required. o This section shall not apply when the child's record contains documentation from the child's prescribing physician that the psychotropic medication has been provided in an emergency, as described in California Rules of Court, rule 5.640 o Procedures for reviewing and evaluating needs & services. (how often and what happens when it is identified that a change is needed) Section 7- Transporting o Clarify if the transportation to and from school is not provided then who will transport the children to school. o How the facility will ensure that no vehicle utilized to transport a client will have been smoked in (weather at rest or in motion.) o How the facility is going to ensure the use of restraint systems as necessary (i.e. car seats for younger children) Section 20- Clothing & Incidentals o How will the facility ensure quantity and quality clothing necessary based on seasons? o Incidentals needed by client how is this determined/obtained for clients that are not receiving P&I. o How does client have a say in the choice of articles of clothing Section 21- Staff Schedule (LIC Optional) o How many hours per week is the administrator required to be present - in the wrong section page 184 states 40 hours 1st 6 months then what will be the requirement? o How many facilities will the administrator oversee? Section 22- Staff Qualifications o Minimum qualifications for each staff position listed on the LIC 500 - missing the facility manager. o Abuse reporting requirements o Number of hours the facility administrator will be at the facility performing administrative functions (not the same as section 21) Section 24- Inservice Training for Staff/Administrator o Complete description of the training plan to include initial and annual training for all positions within the agency - facility manager is missing and needs to be added. o Topics Covered (submit one-month training schedule) and length of each training? o How special training needs are identified and then training met to address o Facility Manager training plan (and required documentation therein) o Level of clients: Intervention training (If the provider will be serving aggressive clients, the applicant needs to address an intervention system - such as CPI or PROACT - into their program and identify staff training and monitoring of the interventions and admission procedures for ensuring compatibility) Section 28- Facility Sketch (LIC Optional) o Number of children per bedroom o Bedrooms labeled as non-ambulatory or ambulatory and if a staff or client bedroom o All indoor and outdoor space used by clients to be labeled accordingly o Location of utility shutoff Other Requirements - o Neighborhood Complaint Policy - Who is designated and phone number for contact (not the facility #) info was blank - Timelines for notification of findings articulated - states asap need to be specific - Complaints/concerns documented and kept on file o Overall, there are some grammatical and typographical errors observed along with sections that are in the wrong areas and mixed together with unrelated sections. Exit interview was conducted and a copy was emailed to applicant for signature and a copy will be placed in application file. Section 13- Discipline Policies - missing for clients and Emergency Intervention Plan mixed in. o Positive Discipline Policies - other discipline permitted o Conditions for use of Discipline (and what types) o Type of discipline NOT permitted (corporal punishment and/or personal rights) o Discipline Policies provided to Placing Agency o Discipline Policies will not violate Personal Rights o NOTE: Prone containment and like techniques not to be included as part of a program's discipline policy nor written into individual needs and services plans. Such techniques are not to be a planned step-in modifying behavior. They are only considered to be last resort emergency physical control techniques designed to prevent injury to the assaultive child or others. Section 14- Emergency Intervention Plan - 1 page mixed with Discipline Policies Section 13 o Copy of the agency's approved Emergency Intervention Plan o Calls to Law Enforcement - When or How to Involve o What Early Interventions, Techniques (including manual restraints), Situations in which techniques will be used, maximum time limits, when techniques NOT used, expected outcomes, Not violate Personal Rights o Emergency Interventions - Reasons for Use o Assessment of underlying or unknown medical or physical condition precluding use of restraints. o Techniques of group and individual behavior management o Methods for de-escalating volatile situations o Alternative methods of handling aggressive and assaultive behavior o Techniques for returning the child to planned activity following an emergency intervention o Name and qualifications of the individual who designed the Emergency Intervention Plan and will be providing training to staff o If not using manual restraints how will facility respond to crisis? Section 15- Runaway Plan o When and how client's absence first noted additional details needed o Circumstances surrounding the client's absence o What actions taken to prevent runaway- interventions utilized if any o Continuum of interventions o Actions to locate client o Post Incident Review and use of manual restraints o Notifications made and to whom, will CCL be notified? o Runaway training plan Section 16- Children's Complaint/Grievance Procedures o Where are the Complaint/Grievance forms kept for easy access o How do clients file a Complaint/Grievance (Not clear) o How will facility respond to Complaints/Grievances? o How will clients and their authorized representatives and staff receive copies of the written complaint/grievance procedures (and sign for) Section 17- Handling of Children's Funds, Allowance & Salaries o Policies & Procedures for handling of client funds/Allowance/Salaries o Accurate Records maintained for payments from client money (receipts maintained) o Not comingled with Licensee funds- mentioned for non-minor dependents but not minors. o Other requirements for handling cash resources upon discharge Section 18- Chores o Are chores paid or unpaid Section 19- Nutrition/Sample Menu o Provisions for children with special dietary needs

met_with: Kedra Creer, Applicant


facility_name: WENWOOD GROUP HOME

summary: Facility Evaluation

raw_content:
Narrative:
On April 11, 2022 at approximately 11: AM, Licensing Program Analyst (LPA) Raymond Wu conducted a visit at the facility for the purposes of initiating a Year Required inspection. LPA met with the representative listed above and discussed the purpose of the visit. During the visit, a walk-through of the facility was conducted. The facility is currently vacant and the last client moved out approximately 2 years ago according to the Administrator. PHYSICAL PLANT A walk-through of the physical plant was conducted at approximately 11: AM. The facility is a single-story home situated in a quiet residential area. The exterior of the facility was observed to be well-maintained and in good repair. After entering the front door, postings, including the License, Emergency Disaster Plan, and Complaint hotline numbers were prominently placed for any potential clients. Towards the left, a living room was observed to be clean, in good repair, and furnished with furniture and entertainment items for potential clients. Moving down, there is a kitchen and dining room. All kitchen cabinets and appliances were observed to be in good repair. No perishable food was observed due to the facility being vacant. Further back, there is a laundry room that is secured. There were a total of 3 bedrooms and 1 bathrooms for client use. All rooms were observed to be clean and furniture was observed to be in good repair. Mattresses were outfitted with mattress covers and linens were clean and tidy. Bathrooms were observed to have paper towel dispensers, trash bins with covered lids, and soap for potential client use. Smoke detectors and carbon monoxide detectors were observed to be functional and a fire extinguisher was observed to have been serviced in the past year. Sharps objects, chemicals, and medication were securely stored in the staff office. All indoor and outdoor passageways were free from obstruction. LPA advised that an annual continuation visit would need to be conducted. No deficiencies were observed or cited during today's visit.

met_with: Administrator Sergio Castaneda


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPAs) T. Davis and Caitlin Chambers went to Wenwood Group Home on August 29, 2024 at 11:35am for the purposes of an unannounced Required Annual inspection. LPAs met with Sergio Castaneda, Assistant Director (AD), and discussed the purpose of today's inspection. LPAs and the AD conducted a tour of the facility. The facility is licensed to serve six (6) male clients ages six to seventeen years of age. Ambulatory only. The facility is located in a residential neighborhood and has three bedrooms, two bathrooms, living room, garage, dining area, staff office, and a kitchen. Currently, there are three clients in placement at the facility. LPAs observed a fully stocked pantry as well as a fully stocked refrigerator in the kitchen. LPAs also observed an abundance of fruit in the kitchen. The kitchen was observed to be clean and well stocked with several food items (perishable and nonperishable). Sharp knives, chemicals, and cleaning supplies are kept locked in areas inaccessible to clients. LPA observed two bathrooms to be in good repair and working order. The First Aid Kit was fully stocked with scissors, tweezers, bandages, band-aids, and a thermometer. Smoke alarms were operable in each bedroom. There is adequate seating in the dining area and the living room. LPAs observed an inoperable fireplace in the living room. The outdoor areas were observed to be free of debris and hazards. LPAs did not observe any pools or other bodies of water on the premises. LPAs observed all three bedrooms with a desk and chair, bed, and closet space. Files were reviewed and were found to be in order. The last fire drill was held on August 14, 2024 at 7:00pm. LPAs obtained a current copy of the facility's staff roster (LIC500) as well as a client roster. LPAs also obtained a copy of the minutes relating to the most recent Board of Director's meeting that was held on May 30, 2024. LPA found no Title 22/ILS deficiencies on this date. Exit interview conducted

met_with: Sergio Castaneda, Assistant Director


facility_name: WEST CHILDREN'S HOME

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
LPA Phillips observed hand sanitizer and cleaning schedule for maintenance staff. Additionally, Staff #1 and Staff #2 all reported wearing mask during shift, temperature checks and reporting all COVID to proper authorities. All staff interviewed report cleaning hands and reporting illness of residents and self as required by facility and health department. LPA Phillips reviewed special incident reports and found incidents reported to department as required. LPA Phillips observed facility to be clean safe and sanitary. After review of staff interviews , facility reports and LPA Phillips observation the allegations were found to be Unsubstantiated. No deficiencies cited at the time of this investigation. Exit interview was conducted, and copy of the report will be emailed to Annielyn Dumas facility administrator

Investigation Findings:
13On April 14, 2022 @ 2: PM Licensing Program Analyst (LPA), Zena Phillips conducted a follow-up complaint investigation visit to West Children's Home and met with Blessing Emelu/Lead Staff. The purpose of the visit was to deliver findings for the above complaint allegations. During the investigation process by LPA Phillips, all relevant parties have been accounted for. Based on the interviews conducted, the above allegations are found to be unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred. LPA Phillips observed cleaning solutions and automatic dispenser with thermometer installed at front entrance. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Zena Phillips 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: WEST CHILDREN'S HOMEFACILITY NUMBER: VISIT DATE: 04/14/2022

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

report_type: Complaint Investigation

met_with: Blessing Emelu/Lead Staff.

complaint_status: unsubstantiated


raw_content:
Narrative:
It was reported to LPA Phillips that Administrator is nice to residents in care and tries very hard to get residents what they need. File reviews reveal that staff have completed on hands training with residents in care, communication skills. and ProAct training. Based on the interviews conducted, documentary evidence, the information gathered did not produce corroborating evidence to support the above said allegations. LPA Phillips was not able to determine if the above said allegations occurred, therefore the allegations are determined to be unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. Based on the observations made during today's visit, no deficiencies were cited. Exit interview was conducted, and a copy of this report will be emailed to the Administrator.

Investigation Findings:
13On 11/03/2022 @ 2:10PM Licensing Program Analyst (LPA) Zena Phillips made a follow up visit for the purpose of delivering findings on the allegations. LPA Phillips was greeted by Ngozi Emelu/Lead Staff who granted acces to the facility and provided the census.. During the investigation of the allegations: Staff member speaks inappropriately to minors while in care. Staff member threatens minors while in care LPA Phillips conducted ten (10) confidential interviews. LPA Phillips reviewed facility file and IEP for Child #1 and Child #2 in care. Confidential interviews and documentary evidence did not substantiate the allegations. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Zena Phillips 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: WEST CHILDREN'S HOMEFACILITY NUMBER: VISIT DATE: 11/03/2022

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

met_with: Ngozi Emelu/Lead Staff


summary: Facility Evaluation

raw_content:
Narrative:
On 09/22/21 at 11: AM, Licensing Program Analyst (LPA), Zena Phillips made an unannounced visit to the West Children's Home to conduct a required annual /required inspection. LPA Phillips met with Linda Hudson/Administrator, who granted access to facility. State of CA license was posted. LPA Phillips inspected the home. During the inspection of the home the following was observed: Facility is clean, safe, sanitary, and in good repair. Passageways, stairways, inclines, ramps and open porches are unobstructed. Disinfectants, cleaning solutions, and poisons inaccessible to clients. Children were not in home at time of inspection off site attending school. Facility has non-perishable foods for one week and perishable foods for two- days. Meals are provided by cafeteria and staff pick up food three meals per day Facility provides nutritious between meal snacks. Medications locked/accessible only to employees supervising stored medications. Facility Staff confirmed there are no firearms/dangerous weapons. . LPA Phillips advised Facility personnel to report violations of personal rights. Facility posts child's right if licensed to provide foster care for six or more children. Children not restricted in telephone use except by court order. Children accorded dignity in personal relationships with staff and others. Children live in a safe, healthy, comfortable facility and are treated with respect LPA will return to interview staff that were not present during the inspection. Exit Interview was conducted and a copy of this report was left at facility.. LPA Phillips was advised that some of the staff would return at 2: PM after picking residents up from school. LPA Phillips returned to facility to interview staff present. LPA Phillips was greeted by Annielyn Dumas/ Program Manager On 09/22//2021 at 2: PM Licensing Program Analysts (LPA's) Zena Phillips, made an announced visit to West Children's Home for Case Management Annual Continuation Inspection LPA Phillips conducted interviews with present staff and all other will be interviewed at a later date. Residents are non verbal and will not interviewed.. LPA Phillips will follow up with Administrator for remaining staff interviews. Exit interview was conducted with Annielyn Dumas/ Program Manager and a copy of this report will be emailed to Administrator. No deficiencies cited at this time.

met_with: Linda Hudson/ Adminastrator


summary: Facility Evaluation

raw_content:
Narrative:
On 09/27/2021 at 9: AM PM Licensing Program Analyst (LPA's) Zena Phillips, made an announced visit to West Children's Home for Case Management Annual Continuation Inspection. LPA reviewed the following during the inspection: Staff records review; the information regarding the Emergency Preparedness. LPA reviewed Criminal Records and confirmed that all current and former staff were also cleared. LPA reviewed The Administrator, and Direct Care staff records. LPA reviewed the facility binder that included specific training's, following a quiz for all staff: Specific Trainings include the following: Policies & Procedures; Health & Safety: Emergency Procedures: Medication; Trauma-Informed Care; Boundaries; Job Duties; and information about the Stakeholders. LPA Interviewed Annielyn Dumas/ Administrator by phone. There were no deficiencies cited at this time. Exit Interview was conducted and a copy of this report will be emailed to Linda Hudosn/Administrator.

met_with: Linda Hudson/Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 08/16/2022 at 8: AM, Licensing Program Analyst (LPA), Zena Phillips made an unannounced visit to the West Children's Home to conduct a required annual inspection. LPA Phillips met with Belinda Sanders/ Direct Support Staff who granted access to facility. State of CA license was posted. LPA Phillips requested the current census of the home and inquired if residents had started school. LPA Phillips was informed two residents began high school and three (3) will begin school the following day. The entire physical plant was inspected. The Group Home is to provide care and supervision for six (6) children, ages 6-17 years Non- Ambulatory Only. Facility has camera waiver on file. The Administrator confirmed that there are no guns or weapons on the premises. This is a 1-story three (3) bedrooms; 2 full- bathrooms home. There is a fully furnished living room with two (2) long sofas with cushions, dining room with seating for six (6) and Central Air conditioning and heating unit. Facility has non-perishable foods for one week and perishable foods for two- days. Meals are provided by cafeteria and delivered three meals per day. Facility provides nutritious between meal snacks. Medications locked/accessible only to employees supervising stored medications The outdoor perimeter front yard, side yard and backyard were inspected and found cleared of debris and hazards materials. Shut off valve for gas located on north side of home and electric shut off located on south side of home. There is a swing set with adequate secure straps for residents to swing safely. .cont on 809 c LPA Phillips observed each bedroom is equipped with two twin beds in good condition with clean linens and pillows. There is a dresser in each room with four (4) drawers for storage. There is adequate closet space for clothing and personal storage. The hallway is equipped with a linen cabinet well stocked with clean towels, sheets, blankets and additional pillows. LPA Phillips observed washer and dryer unit with locked cabinet above for storage of laundry and cleaning supplies. LPA Phillips observed two full bathrooms clean safe and sanitary with necessary grab bars to aid in showering of residents safely. LPA Phillips observed two (2) fully charged fire extinguisher. LPA Phillips confirmed smoke alarms are fully functioning with the assistance of maintenance staff. LPA Phillips observed smoke detector in entry way, main living room, kitchen, two ( 2) in the hallway, smoke detector in all three (3) bedrooms. LPA Phillips reviewed three (3) client files, medical logs, NSP, confirmed authorized representative signature on file, with physician/ dental address and phone number listed. LPA Phillips observed client files to be in order. LPA Phillips reviewed four (4) staff files and observed valid identification, criminal record clearance with signature, valid CPR cards, most recent training's which included trauma informed care, Proact and Sexual Harassment and HIPPA training. LPA Phillips observed job duties and education requirements along with Relias certificates. LPA Phillips interviewed three (3) staff , was unable to interview residents due to non verbal. LPA Phillips observed the facility to be clean, safe and sanitary. There were no deficients cited at this time Exit interview was conducted and report will be emailed to John Paul Adeleye/Administrator .

met_with: Belinda Sanders/Direct Support Staff


summary: Facility Evaluation

raw_content:
Narrative:
On 09/22/2023 at 8: AM, Licensing Program Analyst (LPA), Zena Phillips and Deborah Lee made an unannounced visit to the West Children's Home to conduct a required annual inspection. The Group Home is to provide care and supervision for six (6) children, ages 6-17 years Non- Ambulatory Only. Facility has camera waiver on file. LPA Phillips and LPA Lee conducted inspection of files at main campus due to facility renovations. LPA Phillips and LPA Lee met with Annielyn Dumas/Administrator who provided client and staff files as requested. LPA Phillips conducted review of five (5) of staff, five (5) of client's files.L PA Phillips and LPA Lee reviewed five (5) client files, medical logs, NSP, confirmed authorized representative signature on file, with physician/ dental address and phone number listed. LPA Phillips and LPA Lee observed client files to be in order. LPA Phillips reviewed five (5) staff files and observed valid identification, criminal record clearance with signature, valid CPR cards, most recent training's which included trauma informed care, Proact and Sexual Harassment and HIPPA training. LPA Phillips observed job duties and education requirements along with Relias certificates Facility personnel meet staff qualifications requirements. Facility personnel meet staff training requirements. Children's records contain authorization for emergency medical care signed by each child's authorized representative. Children's records contain individual service plan signed by their authorized representative. LPA Phillips and LPA Lee advised Annielyn Dumas will return to complete physical plant inspection and staff interviews at a later date. LPA Phillips and LPA Lee observed temporary facility and one client on site, LPA Phillips and LPA Lee observed facility to be clean safe and sanitary. . There are no deficiencies cited during today's visit. Exit interview completed. LPA Phillips advised report will be emailed to Annielyn Dumas Administrator.

met_with: Shieley Starks/ Mileu Counselor


summary: Facility Evaluation

raw_content:
Narrative:
On October 5, 2023 @ 10: AM Licensing Program Analyst (LPA) Zena Phillips made an announced visit for the purpose of conducting a Case Management visit inspection. LPA was greeted by John Paul Adeleye/Administrator who granted access to the facility. The facility is licensed to care for six (6) children ages 6 to 17 and non ambulatory. At that time of inspection, the census was zero (0). During the inspection of the home the following was observed: Passageways, stairways, inclines, ramps and open porches are unobstructed. Disinfectants, cleaning solutions, and poisons inaccessible to clients. LPA observed all four (4) smoke detectors are working properly and two fully charged wall mounted fire extinguishers. LPA observed three (3) bedrooms equipped with two new twin beds in good condition with clean linens and pillows. There are new dressers in each room with six (6) drawers for storage. There is adequate closet space for clothing and personal storage. Each bedroom is newly painted, refurbished screens on each bedroom window and new overhead lighting. Temperatures in client rooms and common areas were found to be between 68 - 85 degrees (F). LPA observed two full bathrooms clean safe and sanitary with necessary grab bars to aid in showering, non- slip rugs for residents safely. LPA observed new tile flooring, walk in showers, new stand alone pedestal sink and new toilet. The bathroom windows has refurbished screen in good repair. The hallway is equipped with a linen cabinet well stocked with new towels, sheets, blankets and additional pillows. LPA observed washer and dryer unit with locked cabinet above for storage of laundry and cleaning supplies. LPA observed newly installed wood flooring throughout the facility. cont on 809c LPA observed the front office space to have second wall mounted fire extinguisher fully charged, first aid cabinet to be in compliance fully stocked. LPA observed the following posted documents: Personal Rights, Facility License and facility sketch in all rooms in showing emergency escape exits. LPA observed the living room with two new sofas adequate seating for six(6). The walls have been painted, new recessed lighting, two windows with refurbished screens in good repair with new blue curtains on each window. LPA observed dining area with new large table, with six( 6) chairs, three windows with new blue curtains all in good repair. LPA observed the kitchen new granite counter tops, new five burner stove all in working order, new microwave, new sink and faucet, new double door refrigerator, mounted microwave above stove, and LPA confirmed water temperature meets regulations requirements of not more than 120 degrees (F). LPA observed newly installed upper and lower kitchen cabinets. LPA observed bowls, plates, cups and adequate utensils for residents. LPA observed locked lower cabinets for sharps. Locked lower cabinet under sink for cleaning solutions, trash can has closed lid. The facility has cleaning staff that come twice (2) a week for facility maintenance. LPA observed the rear yard with safety ramp, table with center umbrella with four (4) chairs. LPA observed swing set for two (2), ground mounted, with safety harness straps for residents. All exterior trash cans have lids, garaged is key locked and used for storage of facility supplies. There are no deficiencies observed or cited at this during this inspection. Facility is clean, safe, sanitary, and in good repair. LPA observed the facility to ready for residents to return. An exit interview was conducted with the Administrator, and copy of the report was provided to the facility.

met_with: John Paul Adeleye/Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 10/18/2023 at 8: AM, Licensing Program Analyst (LPA), Zena Phillips made an unannounced visit to the West Children's Home to conduct a required annual inspection continuation. LPA met with Shirley Starks /Milieu Counselor who provided current census. LPA conducted staff interviews and toured entire facility. LPA conducted four (4) staff interview, no residents were interviewed due to non verbal. During today's inspection residents returned home from school and were attended to by staff on site with afternoon snacks and activities. During the inspection of the home the following was observed: Facility is clean, safe, sanitary, and in good repair. Passageways, stairways, inclines, ramps and open porches are unobstructed. Disinfectants, cleaning solutions, and poisons inaccessible to clients. Children in care are supervised & protected at all times. Facility has non-perishable foods for one week and perishable foods for two- days. Facility provides nutritious between meal snacks. Medications locked/accessible only to employees supervising stored medications. Facility Staff confirmed there are no firearms/dangerous weapons. Children in care are supervised & protected at all times. This is a 1-story three (3) bedrooms; 2 full- bathrooms home. There is a fully furnished living room with two (2) long sofas with cushions, dining room with seating for six (6) and Central Air conditioning and heating unit. Facility has non-perishable foods for one week and perishable foods for two- days. Meals are provided by cafeteria and delivered three meals per day. Facility provides nutritious between meal snacks. Medications locked/accessible only to employees supervising stored medications. The outdoor perimeter front yard, side yard and backyard were inspected and found cleared of debris and hazards materials. Shut off valve for gas located on north side of home and electric shut off located on south side of home. There is a swing set with adequate secure straps for residents to swing safe LPA observed two (2) bedroom equipped with two twin beds in good condition with clean linens and pillows. There is a dresser in each room with four (4) drawers for storage. There is adequate closet space for clothing and personal storage. One (1) bedroom with one twin bed close to the ground due to resident preference. There is adequate storage space for clothing in the closet and drawers. Temperatures in client rooms and common areas were found to be between 68 - 85 degrees (F). . cont on 809 c The hallway is equipped with a linen cabinet well stocked with clean towels, sheets, blankets and additional pillows. LPA observed new washer and dryer unit with locked cabinet above for storage of laundry and cleaning supplies. First Aid kits checked and found to be complete. Hot water was tested and found to be between 105-120 degrees (F). LPA observed two full bathrooms clean safe and sanitary with necessary grab bars to aid in showering of residents safely. LPA observed two (2) fully charged fire extinguisher. LPA confirmed smoke alarms are fully functioning with the assistance of maintenance staff. LPA observed smoke detector in entry way, main living room, kitchen, two ( 2) in the hallway, smoke detector in all three (3) bedrooms. There are no deficiencies cited during today's visit. Exit interview completed and report will be provided to John Paul/ Administrator. LPA observed cameras on the outside perimeter of the buildings. The cameras are monitored by the administrative staff and the IT Department. There is a camera waiver on file.

met_with: Shirley Starks/ Milieu Counselor


facility_name: WHITE FAMILY GROUP HOME

raw_content:
Narrative:
Youth admitted to being physically aggressive with staff after youth was not initially allowed to do laundry. Youth explained that although youth hit staff, staff responded by hitting youth, resulting in an eye injury. The injury was observed by school staff which led to youth explaining the incident leading to youth's eye injury to school and law enforcement personnel. Staff corroborated the series of events leading up to the physical altercation but denied hitting the youth. Staff admitted to holding on to youth's hands to prevent youth from continuously hitting staff in the eye, until youth was able to calm down. Staff denied observing any injuries to youth after the incident. Staff sustained an eye injury as a result of being hit by youth. LPA reviewed the medical report and photos pertaining to youth's eye injury. Other records show consistent information regarding the events prior to the physical altercation. However, youth gave varying accounts of how staff reacted during the physical altercation. At the time of the incident, only one other youth, who is non-verbal, was at the facility but this youth was in another room and, per statements from staff and youth, did not witness the incident. Regarding staff holding the youth's hands down, staff was preventing the continuous physical assault by youth towards staff and was redirecting youth to stop the assault and to calm down. Youth eventually calmed down and was able to proceed in completing youth's requested task. Based on the above information, the allegation is unsubstantiated. Although the allegation may have happened or is valid, the preponderance of evidence to prove the allegation was not met. A copy of this signed report, the Confidential Names and Appeal Rights forms were provided to the facility representative. No deficiency citation was issued.

Investigation Findings:
13On March 29, 2022 at 8: AM, Licensing Program Analyst (LPA) Irene Yamamoto conducted a complaint inspection at the facility to deliver the finding of the allegation. LPA met with the facility representative named above. LPA investigated the allegation by conducting confidential interviews with foster youths, staff and other related parties. Records were reviewed such as, but not limited to, the Register of Clients in placement, Personnel Report, Individualized Program Plan (IPP), Incident Report, Medical Report and Photos, Placement Agency and Law Enforcement reports. It was alleged that staff hit youth while in care, resulting in injury. Confidential records reveal that youth became verbally aggressive towards staff after being told that youth cannot do laundry due to a scheduled tele health session. At the end of the tele health session, staff went to the youth's room and informed youth that youth can do laundry. Youth responded by punching staff several times in the left eye. Staff held on to youth's hands and asked youth to calm down. Both individuals fell on youth's bed where staff continued to hold on to youth's hands until youth calmed down. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Irene Yamamoto LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: WHITE FAMILY GROUP HOMEFACILITY NUMBER: VISIT DATE: 03/29/2022

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

met_with: Michael White, Director


raw_content:
Narrative:
The investigation revealed the following: It was alleged that Staff 1 (S1) cause injury to minor. S1 denied the allegation. S1 stated he was not working at time of incident. Review of staff schedules corroborated that S1 was not present. Staff 2 (S2) was the only one working at time incident occurred and denied causing injury to youth. S2 stated that C1 became to experience a mal-adaptive episode which was normal for him and grab S2 by her wrist. S2 struggled to free herself, pulling away from C1. C1 released S2 and began to hit himself with a closed fist in the face. S2 was redirecting youth to stop the assault and to calm down. Youth eventually calmed down and went on as if nothing happened. Due to the cognitive disability of the C1 interview was not able to be conducted. There were no witnesses to incident. Based on the information gathered, although the allegations may have happened or is valid, the preponderance of evidence to prove the allegations was not met, therefore the allegation is unsubstantiated. An exit interview was conducted. A copy of this report Confidential Names Form, and Appeal Rights were provided to Administrator. There were no deficiencies cited during this inspection.

Investigation Findings:
13On May 1, 2024, at 12: PM, Licensing Program Analyst (LPA) Angelina Garibaldo conducted a complaint inspection at the facility to deliver the finding of the allegation. LPA met with the facility representative named above. LPA investigated the allegation by conducting confidential interviews with foster youths, staff, and other related parties. Records were reviewed such as, but not limited to, the Register of Clients in placement, Personnel Report, Individualized Program Plan (IPP), Incident Report, Staff Schedules, Placement Agency, and Regional Center reports. It was alleged that staff member caused an injury to minor. Confidential records reveal that youth had a mal-adaptive behavior and became aggressive towards staff. During incident youth sustained an injury to his top lip that did not require medical attention. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Angelina Garibaldo LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: WHITE FAMILY GROUP HOMEFACILITY NUMBER: VISIT DATE: 05/01/2024

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

met_with: Micheal White- Administrator


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analysts (:LPAs) Gilbert Gutierrez, Pamela Silva, and Jenny Mundo on November 29, 2021 at 9:00am. During the inspection, LPAs met with Michael White, Administrator. LPAs conducted a facility tour with the Administrator at 9: AM. The facility is clean, safe, sanitary and in good repair. All medications are centrally stored, locked and accessible only to employees responsible for stored medications. LPAs reviewed the facility's Program Statement. LPAs reviewed two (2) staff files and zero (0) client files due to the facility not having clients whom are dependents of the court. LPAs interviewed two (2) staff. LPAs conducted an exit interview. No deficiencies are being cited at this time. A copy of this report was provided to the facility representative along with Confidential Names list (LIC 811).

met_with: Michael White


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Zeyda Loera conducted an unannounced Annual inspection at the above-named facility on July 28, 2022 at 10: PM. LPA met with Michael White, Administrator. This facility is licensed to serve ambulatory children ages 12-17 currently there are 2 clients placed in the home by San Gabriel Pomona Regional Center. LPA and Administrator toured the facility. LPA obtained and reviewed the following updated documentation: LIC Personnel and Client Roster Board of Directors report and Program Statement Employee Grievance Policy/ Grievance Procedures Crisis Prevention Intervention Training's Emergency Preparedness: Disaster and Mass Casualties Drills Emergency Evacuation Routes Facility Monthly Activities Calendar Emergency Intervention Plan Complaint Procedures Continue 809-C...... The facility was in full compliance with 7 applicable areas of the Compliance and Regulatory Enforcement (CARE) tools for Children's Residential Licenses. Annual compliance review consisted of the following domains: Physical plant, operations, disaster preparedness plan, emergency intervention, staffing, and client records. Community Care Licensing (CCL) focuses its efforts on three priority areas: prevention, compliance, and enforcement. Two fire extinguisher throughout the facility is fully charged and last serviced on 12/13/2021. The facility has a working telephone that is accessible to clients and staff. All passageways and grounds were free of any obstructions. The medications, cleaning solutions, and knives were locked inside the cabinets in the kitchen inaccessible to the clients. There was perishable foods enough for 3 days and non-perishable foods enough for client's consumption for more than a week. Each bedroom has two (2) twin bed with clean sheets and linens. There were drawers and closet space in each bedroom for client use. The hot water temperature was tested and was in working order. At the time of this inspection the facility was observed to be clean, safe, and in good repair. Administrator is on site at least 20 hours a week. The facility has a Chevrolet Tahoe 8 passenger Truck to transport clients. They contained all safety requirements required by the law. The facility maintains an equipment/vehicle safety log. Vehicle was serviced on 11/20/21. For this review, LPA randomly selected 3 staff files and 2 client files for review. Additionally, LPA reviewed two (3) staff files for compliance with Title Regulations and Interim Licensing Requirements. LPA also conducted interviews with one staff members and two client are non-verbal. An exit interview was conducted. LPA provided the facility representative above a signed copy the LIC 809 and LIC 811 reports. There were no deficiencies cited at the time of this inspection.

met_with: Michael White, Administrator


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On February 22, 2023 at 9: AM. Licensing Program Analyst (LPA) Gilbert Gutierrez conducted an unannounced annual inspection at the above-named facility. At the time, LPA arrived no one was home but Administrator, Michael White arrived shortly. This facility is licensed to serve 4 ambulatory children ages 12-17; currently there are 3 placement. Physical Plant: At the time of the inspection, the following was observed: a posted license, children's personal rights, emergency disaster plan, facility menu, and staff schedule. There was non -perishable foods for at least a week and perishable foods for at least two days. All medications, sharp objects, disinfectants,and cleaning solutions are locked. There is a centralized heater in the facility and the thermostat is maintained at 70 degrees (F). The hot water temperature was 120 degrees F. Each client bedroom has 2 beds with clean linens and blankets. There is also adequate drawer/cabinet space for client use. The first aid kit is complete. The smoke detectors and carbon monoxide alarm were tested and working. The Emergency Disaster Mass Casualty Plan is current and available for review. The (2) fire extinguishers were last serviced on 12/19/22. The facility has a working telephone. The facility is clean, safe, sanitary, and in good repair. Staff Records: LPA reviewed 2 personnel records. Adults working in the facility have DOJ/FBI criminal record clearances and Child Abuse Index Checks. Staff files are maintained locked inside a cabinet. Client Records: LPA reviewed 2 client records. Client records are maintained locked in hallway cabinets. LPA interviewed 1 staff and 1 client. An exit interview was conducted, and a signed copy of the LIC 809, LIC 809C, LIC 809D and LIC 9102 were provided to the facility administrator. Two deficiency citations were issued at the time of the inspection.

Deficiencies:
84065(d): Personnel Requirements

(d) The licensee shall designate at least one facility manager to be present at the facility at all times when children are present


summary: Facility Evaluation

raw_content:
Narrative:
On February 16, 2024, at 9: AM, Licensing Program Analyst (LPA) Gilbert Gutierrez conducted an unannounced annual inspection at the above-named facility and met Administrator, Michael White. The facility is licensed to serve 4 ambulatory children ages 12-17; currently there are 2 placements. Physical Plant: Administrator White gave the tour of the facility and LPA observed the following: a posted license, children's personal rights, emergency disaster plan, facility menu, activity schedule, staff, and grievance procedure. There were non -perishable foods for at least a week and perishable foods for at least two days. All medications, sharp objects, disinfectants, and cleaning solutions are locked inside the cabinets. There is a centralized heater in the facility and the thermostat is maintained at 70 degrees (F). The hot water temperature was 120 degrees F. Each bedroom has 2 beds with clean linens, blankets, and adequate drawer/cabinet space for clients' use. The first aid kit is complete. The smoke and carbon monoxide detectors were tested and working. The Emergency Disaster Mass Casualty Plan is current and available for review. The fire extinguishers located in the kitchen area and in the garage were serviced in January 2024. The facility has a working telephone. The facility is clean, safe, sanitary, and in good repair. Staff Records: LPA reviewed 4 personnel records. All staff working in the facility have DOJ/FBI criminal record clearances and Child Abuse Index Checks. Staff have current CPR and First Aid and annual training. Staff files are maintained locked inside a cabinet. Client Records: LPA reviewed 2 client records. The client records are available for review and are maintained locked in the cabinet. An exit interview was conducted, and a signed copy of the LIC 809, LIC 809C, and LIC 811 were provided to the facility administrator. No deficiency citation was issued at the time of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On February 25, Licensing Program Analysts (LPA) Angelina Garibaldo conducted an unannounced annual/required inspection at the above-mentioned facility. and met with Administrator, Michael White. The facility is licensed to serve 4 ambulatory children ages 12-17; currently there are 4 placement's. LPA obtained and reviewed the following updated documentation: · LIC Personnel and Client · LIC C and Emergency Disaster Plan Annual compliance Review consisted of the following (6) domains: physical plant, operations, disaster preparedness plan, emergency intervention, staffing, and client files. One Staff and one Clients were interviewed. Physical Plant: Administrator White gave the tour of the facility and LPA observed the following: a posted license, children's personal rights, emergency disaster plan, facility menu, activity schedule, staff, and grievance procedure. There were non-perishable foods for at least a week and perishable foods for at least two days. All medications, sharp objects, disinfectants, and cleaning solutions are locked inside the cabinets. Each bedroom has 2 beds with clean linens, blankets, and adequate drawer/cabinet space for clients' use. The first aid kit is complete. The smoke and carbon monoxide detectors were tested and working. The Emergency Disaster Mass Casualty Plan is current and available for review. The facility is clean, safe, sanitary, and in good repair. Staff Records: LPA reviewed 2 personnel records. All staff working in the facility have DOJ/FBI criminal record clearances and Child Abuse Index Checks. Staff have current CPR and First Aid and annual training. Staff files are maintained locked inside a cabinet. Client Records: LPA reviewed 2 client records. The client records are available for review and are maintained locked in the cabinet. An exit interview was conducted, and a signed copy of the LIC 809, LIC 809C, and LIC 811 were provided to the facility administrator. No deficiency citation was issued at the time of the inspection.

met_with: Michael White - Administrator


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Angelina Garibaldo conducted an unannounced Annual inspection at the above-named facility on February 20226, at 10: PM. LPA met with Michael White, Administrator. This facility is licensed to serve ambulatory children ages 12-17 currently there are 3 clients placed in the home by San Gabriel Pomona Regional Center. LPA and Administrator toured the facility. LPA obtained and reviewed the following updated documentation: · LIC Personnel · LIC Client Roster · LIC 610C and Emergency Disaster Plan · Board of Directors report Annual compliance Review consisted of the following (6) domains: physical plant, operations, disaster preparedness plan, emergency intervention, staffing, and client files Cont... Physical Plant: Administrator White gave the tour of the facility and LPA observed the following: a posted license, children's personal rights, emergency disaster plan, facility menu, activity schedule, staff, and grievance procedure. There were non-perishable foods for at least a week and perishable foods for at least two days. All medications, sharp objects, disinfectants, and cleaning solutions are locked inside the cabinets. Each bedroom has 2 beds with clean linens, blankets, and adequate drawer/cabinet space for clients' use. The first aid kit is complete. The smoke and carbon monoxide detectors were tested and working. The Emergency Disaster Mass Casualty Plan is current and available for review. The facility is clean, safe, sanitary, and in good repair. Staff Records: LPA reviewed 3 personnel records. All staff working in the facility have DOJ/FBI criminal record clearances and Child Abuse Index Checks. Staff have current CPR and First Aid and annual training. Staff files are maintained locked inside a cabinet. Client Records: LPA reviewed 3client records. The client records are available for review and are kept locked in the cabinet. An exit interview was conducted, and a signed copy of the LIC 809, LIC 809C, LIC9102 and LIC 811 were provided to the facility administrator. Two Technical Assistance were issued at the time of the inspection.


facility_name: WHITE GROUP HOME

summary: Facility Evaluation

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Narrative:
On January 28, 2022 at 10am Licensing Program Analyst, (LPA) Donald Martin conducted an Annual/Required inspection of White Group Home. LPA met with Administrator, Antonia White and conducted an inspection of the facility inside and out. The facility set up is as follows: The facility is a Two story, Six Bedroom home with 3 bathrooms Bedroom #1, 2,3 & 4 are located upstairs and were all set up for single client occupancy. Each room contained one bed and one dresser. There was ample closet space and each room had sufficient clothing for each client. The bedrooms were very clean and in order. The master bedroom was kept locked and contained a bed that used to belong to the Administrator. There is also a bathroom in the room that inaccessible to the clients. Bedroom #5 is located downstairs and has a vacant day bed, is utilized as isolation area/office. There is no body of water on premises. Children are supervised all the time according to staff. Facility is clean, safe and in good repair. No passage ways, inclines, stairways, ramps or open porches are obstructed. Disinfectants/poisons and other hazardous items are inaccessible. There is an adequate food supply (2 day perishable and at least 7 day non-perishable). Nutritious snacks are served between meals. Medication was checked. Medication on is locked except to supervising employees. Personal Rights are upheld, posted & Staff have been instructed to report Personal Rights Violations. Facility operates within its licensed conditions & limitations, including capacity. There are no excluded persons on premises per Administrator. Cont 809-C LPA reviewed two staff files and two client files. All documents were present and all files were in order. LPA interviewed two staff. No clients were present at the time of the visit. The overall home was very clean and in order. There were no deficiencies cited at the time of the visit. A copy of this report is being left with Administrator, Antonia White.

met_with: Antonia White-Administrator


summary: Facility Evaluation

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Narrative:
On April 28, 2023 at 10am Licensing Program Analyst, (LPA) Donald Martin conducted an Annual/Required inspection of White Group Home. LPA met with Administrator, Antonia White and conducted an inspection of the facility inside and out. The facility set up is as follows: The facility is a Two story, Six Bedroom home with 3 bathrooms Bedroom #1, 2,3,4 and 5 are located upstairs and were all set up for single client occupancy. Each room contained one bed and one dresser. There was ample closet space and each room had sufficient clothing for each client. The bedrooms were very clean and in order. The master bedroom was kept locked and contained a bed that used to belong to the Administrator. There is also a bathroom in the room that inaccessible to the clients. Bedroom #6 is located downstairs and has a vacant day bed. The room is utilized as isolation area/office. The backyard is spacious with a lot of trees, plants and a shaded sitting area. The yard was free from debris and or hazards. The shut off valves are located in the backyard. There is no body of water on premises. Children are supervised all the time according to staff. Facility is clean, safe and in good repair. No passage ways, inclines, stairways, ramps or open porches are obstructed. Disinfectants/poisons and other hazardous items are inaccessible. There is an adequate food supply (2 day perishable and at least 7 day non-perishable). Nutritious snacks are served between meals. Cont 809-C Medication was checked. Medication is double locked and each client has their own personal case where the medication is kept. License, Grievance, Mass Disaster and Personal Rights are upheld, posted & Staff have been instructed to report Personal Rights Violations. Note: LPA instructed Administrator, Antonia White to place a new grievance box underneath the grievance posting for clients to access. Facility operates within its licensed conditions & limitations, including capacity. There are no excluded persons on premises per Administrator LPA reviewed two staff files and two client files. All documents were present and all files were in order. LPA interviewed two staff. The clients are non verbal. The overall home was very clean and in order. There were no deficiencies cited at the time of the visit. A copy of this report is being left with Administrator, Antonia White.


summary: Facility Evaluation

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Narrative:
On July 30, 2024 at 1pm Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of conducting an Annual/Required inspection. LPA was met by Gary Moody-Direct Support Provider, and allowed into the facility. The facility capacity is 4 ambulatory, developmentally disabled clients. The facility layout is as follows: The facility is a Two story, Six Bedroom home with 3 bathrooms There are 5 bedrooms located upstairs. 4 of the bedrooms are set up for single client occupancy. Each room contained one bed and one dresser. There is closet space and each room had sufficient clothing for each client. The bedrooms were very clean and in order. The master bedroom was kept locked and not in use and not accessible to the clients and staff. There is also a bathroom in the room that inaccessible to the clients. There is a full bathroom in the hallway upstairs that is shared by all the clients. The bathroom is clean and in good working condition. Bedroom #6 is located downstairs and stays locked and inaccessible to clients. The room is utilized as isolation area.The backyard is spacious with a lot of trees, plants, a trampoline and a shaded sitting area. The yard was free from debris and or hazards. The shut off valves are located in the backyard. There is no body of water on premises. Children are supervised all the time according to staff. Facility is clean, safe and in good repair. No passage ways, inclines, stairways, ramps or open porches are obstructed. Disinfectants/poisons and other hazardous items are inaccessible. There is an adequate food supply (2 day perishable and at least 7 day non-perishable). Nutritious snacks are served between meals. Cont 809-C The kitchen has a stove in good working condition, a refrigerator that was filled with perishable food, and a microwave. There is a menu and cabinets filled with non perishable foods. There is a living room with a large seating area for clients to watch TV. There is a dining area with a large table an chairs. Behind the table is another sectional for clients to sit. The garage is where the company vehicle is kept. It is a 4 door Honda Accord with current registration. Medication was checked. Medication is locked in a closet along with the sharps. Each client has their own personal case where the medication is kept. License, Grievance, Mass Disaster and Personal Rights are upheld, posted & Staff have been instructed to report Personal Rights Violations. Facility operates within its licensed conditions & limitations, including capacity. There are no excluded persons on premises per Administrator All documents were present and all files were in order. The overall home was very clean and in order. There were no deficiencies cited at the time of the visit. A copy of this report is being left with Gary Moody-Direct Support Provider.

met_with: Gary Moody-Direct Support Provider


summary: Facility Evaluation

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Narrative:
On January 31, 2025 at 10am Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of conducting an Annual/Required facility inspection. LPA was met by Direct Care Staff, Megan Murrell and allowed into the facility. The facility capacity is 4 ambulatory, developmentally disabled clients. The facility layout is as follows: The facility is a Two story, Six Bedroom home with 3 bathrooms There are 5 bedrooms located upstairs. 4 of the bedrooms are set up for single client occupancy. Each room contained one bed and one dresser. There is closet space and each room had sufficient clothing for each client. The bedrooms were very clean and in order. The master bedroom was kept locked and not in use and not accessible to the clients and staff. There is also a bathroom in the room that inaccessible to the clients. There is a full bathroom in the hallway upstairs that is shared by all the clients. The bathroom is clean and in good working condition. There is a Dayroom/Office is located downstairs and stays locked and inaccessible to clients. The room can also be utilized as an isolation area. The backyard is spacious with a lot of trees, plants, a trampoline and a shaded sitting area. The yard was free from debris and or hazards. The shut off valves are located in the backyard. There is no body of water on premises. Children are supervised all the time according to staff. Facility is clean, safe and in good repair. No passage ways, inclines, stairways, ramps or open porches are obstructed. Disinfectants/poisons and other hazardous items are inaccessible. There is an adequate food supply (2 day perishable and at least 7 day non-perishable). Nutritious snacks are served between meals. Cont 809-C The kitchen has a stove in good working condition, a refrigerator that was filled with perishable food, and a microwave. There is a menu and cabinets filled with non perishable foods. There is a living room with a large seating area for clients to watch TV. There is a dining area with a large table an chairs. Behind the table is another sectional for clients to sit. The garage is where the company vehicle is kept. It is a 4 door Honda Accord with current registration and insurance. Medication was checked. Medication is locked in a closet along with the sharps. Each client has their own personal case where the medication is kept. License, Grievance, Mass Disaster and Personal Rights are upheld, posted & Staff have been instructed to report Personal Rights Violations. Facility operates within its licensed conditions & limitations, including capacity. There are no excluded persons on premises per Administrator All documents were present and all files were in order. No clients were present at the time of the visit. All clients have limited verbal skills. The overall home was very clean and in order. There were no deficiencies cited at the time of the visit. A copy of this report is being left with Direct Care Staff, Megan Murrell.

met_with: Megan Murrell-Direct Care Staff


facility_name: WINDSOR MANOR

summary: Complaint Investigation - Unsubstantiated

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Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Cheyenne McCambridge met with House Manager Leonardo Dela Cruz regarding a complaint investigation at the group home. The purpose of the inspection was to deliver the findings for the above allegation. During the course of the investigation LPA conducted confidential interviews and reviewed records. LPA was unable to interview youth involved due to them being nonverbal. Through interviews and documentation it was stated that the client does exhibit self injurious behaviors. This department has investigated the allegations, and although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that minor sustained multiple unexplained bruises while in care; therefore, the above allegations are Unsubstantiated. An exit interview was conducted and no deficiencies were cited. A copy of this report was given to the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Nelson Martinez LICENSING EVALUATOR NAME: Isabel Diego 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: Leonardo Dela Cruz


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Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Brian Bertoli met with Home Manager Mary Joy Tiongco regarding a complaint investigation at the Group Home. The purpose of the inspection was to deliver the findings for the above allegations. During the course of the investigation LPA Bertoli inspected the facility, conducted confidential interviews and reviewed records. The inspection, interviews, and documentation did not confirm the allegations. All parties interviewed except the complainant indicated that the facility is diligent in changing bedding and assiting the youth in keeping clean. LPA made multiple unannounced visits and there was no indication of unclean bedding. This department has investigated the allegations, and although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that Staff left minor soiled for an extended period of time, or Staff did not ensure minor was provided clean linen.; therefore, the above allegations are Unsubstantiated. An exit interview was conducted and no deficiencies were cited. A copy of this report was given to the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Brian Bertoli LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Mary Joy Tiongco


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Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Brian Bertoli met with House Manager Mary Joy Tiongco regarding a complaint investigation at the Group Home. The purpose of the inspection was to deliver the findings for the above allegation. During the course of the investigation LPA Bertoli inspected the facility, conducted confidential interviews and reviewed records. The inspection, interviews, and documentation did not confirm the allegation. The facility reported the incident of a youth biting another youth and took appropriate action to prevent further incidents. Two staff were supervising youth when it occurred. This department has investigated the allegations, and although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove a Lack of care and/or supervision leading to minor sustaining unexplained injuries while in care..; therefore, the above allegations are Unsubstantiated. An exit interview was conducted and no deficiencies were cited. A copy of this report was given to the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Brian Bertoli LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


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Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Brian Bertoli and Investigator (INV) Walter Crockett made an unannounced visit to the Group Home and spoke with Administrator Glenn Vargas.The purpose of the inspection was to deliver the findings for the above allegation. During the investigation, LPA Bertoli conducted confidential interviews and reviewed documentation. Through record review and staff interviews it was determined that a the facility did not have the court authorization for administration of the medication. Based on the information obtained, there is a preponderance of the evidence to prove that Facility did not have required authorization for Psychotropic Medication. Therefore, the above allegation is substantiated. Appeal Rights were provided and discussed, and Title 22 deficiencies were cited. An exit interview was conducted, and a copy of the report was given to the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Brian Bertoli LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 21-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SANTA ROSA RO, NEOTOMAS AVENUE, STE. FACILITY NAME: WINDSOR MANORFACILITY NUMBER: 496890099

met_with: Leonardo de la Cruz


summary: Facility Evaluation

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Narrative:
On the above date, Licensing Program Analyst (LPA) Cheyenne McCambridge met with Administrator, Glenn Vargas, for a prelicensing inspection. The facility is a single story home with four bedrooms and two bathrooms. LPA observed facility grounds inspected. Grounds are clean and free from observable hazard. The facility does not have a swimming pool or any bodies of water. Firearms are not allowed on facility premises. Adequate indoor activity space and materials observed, and outdoor activity space was observed. Chemicals and knifes were appropriately locked. Procedures for locked and centrally stored medications observed. Medications will be in a locked cabinet. Adequate storage space was observed. Individual beds in good repair observed. A supply of extra linens available for bed changes. The house has 4 client bedrooms, single occupancy. Bedrooms are accommodating of all required furnishings. Adequate food storage space observed. Facility will add appropriate supply of foods upon placement of youth in the home. A supply of nonperishable foods were observed on this date. A sample menu was posted.

met_with: Glenn Vargas


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Cheyenne McCambridge conducted an unannounced inspection to the facility for the purpose of conducting an Post Licensing inspection. LPA McCambridge met with Co-Licensee Leonardo Dela Cruz and toured the facility, inside and out. Grounds are clean and free from observable hazard. The facility does not have a swimming pool or any bodies of water. Firearms are not allowed on facility premises. Adequate indoor activity space and materials observed, and outdoor activity space was observed. Chemicals were appropriately locked. Procedures for Locked and centrally stored medications observed. Adequate storage space observed. Individual beds in good repair observed. A supply of extra linens available for bed changes. The house has four client bedrooms, single occupancy. Bedrooms are accommodating of all required furnishings. Adequate food storage space observed. There is an appropriate supply of perishable and non perishable foods in the home. All required documents are posted. Dining room equipped with large table and chairs accommodating of all clients. Facility has two restrooms for client use, one for staff use, all are operable. The home is maintained at a comfortable temperature. There are carbon monoxide and smoke detectors throughout the facility. There were operable fire extinguishers posted throughout the facility. There are complete first-aid kits located in the facility. The facility understands that the hot water temperature must be maintained within the regulation range of 105 - 120 degrees. The water temperature measured at 110 degrees. There are currently two clients in care. The home operates within the capacity and limitations of the license. LPA McCambridge reviewed client and staff files and observed they are complete. One client is nonverbal and one declined to be interviewed therefore no client interviews were conducted. LPA observed clients to be safe and accorded dignity during the inspection. No Title 22 deficiencies cited this date. Exit interview conducted and a copy of the report was left at the facility.