raw_content:
Narrative:
There was a statement made that the FM#2 yelled at Ref. #1, "you crazy ass." The LPA received conflicting statements as to whether FM#2 yelled at and called Ref. #1 the name. FM#2 denied yelling at Ref. #1 and calling her the names, indicating that it was the contrary, Ref. #1 did all the yelling and calling names. The investigation revealed that FM#2 required medical assistance and Ref. #1 refused medical assistance. The LPA was unable to obtain sufficient evidence to corroborate the allegations. There was no preponderance of the evidence to substantiate the allegations. So, although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the allegations are unsubstantiated. There are no deficiencies to be cited regarding this allegation. A copy of this complaint was provided to the facility representative.

Investigation Findings:
On August 15, 2025 at 1:20 p.m., Licensing Program Analyst (LPA), Karen McGee, delivered the findings of a complaint investigation involving Client (see Confidential Names, LIC Ref. #1 dated August15, 2025). The LPA met with Facility Manager, Christopher Richardson. On May 5, 2025, Monterey Park Children's Residential Program (MPCRP), received a complaint with the above mentioned allegations. Confidential interviews were conducted that included, but were not limited to: one client Ref. #1 at their temporary placement, the Supervising Facility Manager (SFM) and Administrator via telephone on August 4, 2025 and Facility Manager (FM), Ref. #2 on August 9, 2025. The LPA did not interview Facility Manager Ref. #3. The LPA reviewed Ref.#1's Needs & Services Plan and the incident report. The investigation revealed that Ref. #1yelled at, spat on and physically attacked FM #2 at the facility after becoming upset because the staff followed Ref. #1 when Ref. #1 left the facility without permission. The investigation revealed that FM#2, who was pregnant attempted to block and disengage Ref. #1. FM#2 denied attacking Ref. #1 and Ref. #1 denied that FM#2 attacked them. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Karen McGee LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELOVED ONES 2FACILITY NUMBER: VISIT DATE: 08/15/2025

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

met_with: Christopher Richardson


state: CA

facility_name: BELOVED ONES 2

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
cont.# The information revealed that the staff at this STRTP take most of their training in an online database, while other training is taken in person. The topics of training include, but are not limited to, crisis intervention, emergency procedures, trauma-informed care, and regulatory compliance. On 04/24/25, LPA Flores conducted a file review at the STRTP, and it was observed that S1's file did not contain a Cardiopulmonary Resuscitation (CPR) and First Aid Training Certificate. LPA Flores, having considered the evidence provided during the investigation, deemed the allegation substantiated. A citation was issued on licensing report LIC809 dated 4/24/2025 for violation of Interim Licensing Standards (ILS), Version 6: Section 87065.1 (b)(8)(A): (8) Facility manager training is in addition to first aid and CPR training, and other training as required in Section 87095.65. (A) Completion of cardiopulmonary resuscitation (CPR) and first aid training shall be demonstrated by current and valid CPR and first aid cards issued by the American Red Cross, the American Heart Association, a training program approved by the State Emergency Medical Services Authority pursuant to Health and Safety Code Section 1797.191, or from an accredited college or university. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. No further inspection is needed. A copy of this report, appeal rights and LIC811 was provided to the facility representative. Exit interview conducted.

Investigation Findings:
13On August 21, 2025, at 10:40AM, Licensing Program Analyst (LPA) Humberto Flores, conducted a follow-up complaint inspection at Beloved Ones Short Term Therapeutic Program (STRTP) and met with Administrator Jeanne Fletcher. The purpose of the inspection was to deliver the findings for the above complaint allegation. The initial information that generated this complaint investigation stated that staff have not completed the training required at the facility . RP states the training is to ensure staff are equipped to handle resident care, crisis intervention, emergency procedures, trauma-informed care, and regulatory compliance. RP states that despite multiple email notifications sent to staff, no action has been taken to complete the training from Relias. LPA Flores investigated the allegation and conducted interviews with the Reporting Party (RP), Executive Director (ED) and staff. A review of Staff Ref #1 (S1) and Ref #2 (S2) (see Confidential Names form LIC811 dated 08/21/2025), training records were conducted, and copies were made. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Humberto Flores LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELOVED ONES 2FACILITY NUMBER: VISIT DATE: 08/21/2025

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

report_type: Complaint Investigation

met_with: Administrator, Jeanne Fletcher

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
On February 15, 2022, at 11:30AM, Humberto Flores, Licensing Program Analyst (LPA), conducted an announced Case Management Inspection at Beloved Ones Short Term Residential Therapeutic Program (STRTP) and met with Desiree Terry. The purpose of the inspection was to verify that the facility meets the requirements for a capacity increase, previously requested, to six (6) children. Currently the facility licensed capacity is one (1) child. LPA Flores inspected the facility and observed that there are 2 beds with mattresses, pillows and bed sheets in room #1, room #2 and room #3. There is a closet in each room with enough space to store clothes and shoes. A copy of the facility sketch was provided upon request. LPA Flores observed that the STRTP meets the requirements to hold a licensed capacity of six (6) children. No further inspection is needed. A copy of this report was provided to the facility representative. Exit interview conducted.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Desiree Terry, Supervisor Facility Manager


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On April 25, 2022, 10:30AM, Licensing Program Analyst (LPAS) Humberto Flores, conducted an unannounced Annual Inspection at Beloved Ones Short Term Therapeutic Residential Treatment (STRTP) and met with Jessica Hatley. LPA Flroes stated the purpose of the inspection to the STRTP representative. During the inspection a copy of the Register of Facility Clients and Personnel Report was provided upon request. The following topics were inspected: PHYSICAL PLANT: A tour of the facility was conducted, along with Jessica Hatley. The License is placed in a prominent place, in the reception are of the facility. Children's foster rights were posted. LPA Flores observed that the facility is clean, safe, sanitary and in good repair. The passageways are unobstructed. There is no swimming pool or body of water. The disinfectants and cleaning solutions were stored away from the kitchen areas, food preparation areas to the children. The food is safe and of the quality and the quantity necessary to meet the needs of the clients. Each meal meets at least 1/3 of the recommended in the USDA Basic Food Group Plan-Daily Food Guide. cont.# Supplies of staples non-perishable foods for one week and perishable foods for two days are maintained in the facility. Medications are locked and accessible only to employees supervising stored medications. The temperature in the rooms that clients occupy are maintained between 68 and 85 degrees (F). The hot water temperature was at 131.7 degrees (F). This is a violation of Interim Licensing Standards (ILS), Section Furniture, Fixtures, Equipment, and Supplies (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This is a violation of the regulations and the Health and Safety Code that, if not corrected, have a direct and immediate risk to the health, safety or personal rights of those in care. A type A citation was issued. Emergency Intervention Plan: LPA Portillo reviewed the program statement and PROACT instruction manual and identified the training that is provided for all staff. The staff receive on-going training to maintain certification. A monthly log is utilized to document manual restraints. There have been no restraint. cont.# Disaster Preparedness Plan: LPA Flores reviewed the disaster and mass casualty plan and other provisions by reviewing the program statement. The facility conducts monthly fire and emergency evacuation drills. Drills are documented and kept in the facility for at least one year. CLIENT RECORDS: LPA Flores reviewed the one (1) client file records. Needs and services is trauma informed, culturally relevant, and age and developmentally appropriate and identified the child's needs: reason for placement, education, personal care and grooming, ability to manage money, visitation information, mental health services and placement information CORE THERAPEUTIC SERVICES: During the inspection review, LPA Flores was able to see that the facility is providing the Short-Term Therapeutic Program (STRTP) core services and support to the individuals in placement. The facility has trauma informed, culturally relevant, age, and developmentally appropriate. The facility is also providing trauma informed core services through agreements with other agencies. OPERATIONAL REQUIREMENTS: During the inspection review, LPA Flores observed the facility maintained an updated roster of the clients with pertinent information. The facility administrator and manager are the responsible and capable staff for communicating with emergency personnel in the facility. The facility has developed, maintained and implemented written complaint procedures cont.# STAFFING RECORDS: During the inspection review, LPA Humberto inspected two (2) staff files and verified that all facility staff was subject to criminal records review, fingerprinted and cleared DOJ, FBI and CACI, training hours. LPA Flores observed that Staff Ref #2 did not have an educational background in the file. This is a violation of Section Personnel Requirements: (1) The facility manager shall meet one of the following requirements prior to employment: (A) Have a Bachelor of Arts or Sciences degree. This is a violation of the regulations and the Health and Safety Code that, without correction, could become an immediate risk to the health, safety or personal rights of clients, or record keeping violation that would impact the care of clients and/or protection of their resources, or a violation that would impact those services required to meet clients' needs. A type B citation was issued. A search and review of Licensing Information System (LIS) was conducted during the inspection. A total of 5 employees listed in the Personnel Report LIC500, were working at the facility without a prior association to the STRTP. The employees working without a prior association are: S1, S3, S4, S5 and S6. This is a violation of the regulations and the Health and Safety Code that, if not corrected, have a direct and immediate risk to the health, safety or personal rights of those in care. A type A citation was issued and a civil penalty of $100 per day for a maximum of 5 days per each employee was assessed, for a total of $2,500.00. A copy of this report, LIC811s and LIC809D and appeal rights was provided to the STRTP representative. Exit interview conducted.

Deficiencies:
87065: (1)

visit_type: Annual

met_with: Jessica Hatley, Administrator

title: Personnel Requirements


summary: Facility Evaluation

raw_content:
Narrative:
On May 20, 2022, at 9:45AM, Humberto Flores, Licensing Program Analyst (LPA), conducted an unannounced Case Management Inspection, at Beloved Ones Short Therapeutic Residential Treatment Program (STRTP) and met with Desiree Nichole Terry. The purpose of the inspection was to gather information about the below incident reported via Special Incident Report (SIR). On 4/25/2022, LPA Flores conducted an Annual/Required Inspection at the STRTP. During the inspection documentation and staff files was reviewed. LPA Flores observed on the LIC500 that Staff Desiree Nichole Terry was hired as a Supervisor Facility Manager without the education Degree that Interim Licensing Standards (ILS) Version 4, Section 87065(f)(1)(A) requires: (f) The licensee shall designate at least one facility manager to be present at the facility at all times when one or more children are present: (1) The facility manager shall meet one of the following requirements prior to employment: (A) Have a Bachelor of Arts or Sciences degree. A citation was issued, and the Plan of Correction (POC) date provided to the STRTP was 05/09/22. cont.# The facility has not provided the documentation required to meet and correct the POC, therefore a civil penalty of one hundred dollars ($100) per day was assessed from 05/10/2022 through 05/20/2022, for a total of $1,100.00. See reference in citation page from 04/25/2022. The facility representative was informed that a civil penalty of $100.00 per day will be assessed until the deficiency is corrected. A copy of this report, LIC421FC and appeal rights was provided to the facility representative. Exit interview conducted.

met_with: Desiree Nichole Terry, Supervisor Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Jenny Mundo and Pamela Silva on August 4, 2022 at 9: AM. During the inspection, LPAs met with Desiree Terry, Supervising Facility Manager. LPAs and the Supervising Facility Manager inspected the facility inside and out. LPAs did not conduct review of child records or interviews due to the facility having clients that do not meet the criteria to have their files inspected. LPAs reviewed three (3) staff personnel files on site at the facility at 9: AM. LPAs interviewed three (3) staff on site at 10:25 am. LPAs conducted exit interview with Desiree Terry, Supervising Facility Manager at 10: AM. LPAs provided the Summary Report to the facility representative upon completion. No deficiencies are being cited at this time.


summary: Facility Evaluation

raw_content:
Narrative:
On 01/31/23 at 9: AM, Licensing Program Analysts (LPAs) Pamela Silva and Ashley Ruacho conducted an unannounced Annual Inspection at the facility. LPAs met with Thandi Smith, Administrator. The facility currently has a provisional Short Term Residential Therapeutic Program (STRTP) license. The STRTP's Mental Health Program Application is pending approval. This STRTP is licensed to serve up to six (6) ambulatory children ages 7-17 years of age. The facility also provides services to non-minor dependents pursuant to W&I Code 16501.1 (C)(1). There is one (1) minor and one (1) non-minor dependent currently in placement. The facility is a single-story home located in a residential area. There are no bodies of water in the premises. At 9: AM, LPAs conducted a walk-through of the entire facility. Physical Plant The license, facility sketch, Personal Rights, Emergency Disaster form, Complaints poster, Foster Youth Bill of Rights, Complaints/Grievance policy, emergency phone numbers and menus are posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions and sharps are kept inaccessible in a locked closet in the hallway. Facility has non-perishable food for at least one week and perishable food for at least two days. Medications are centrally stored in a locked cabinet in the staff office. Smoke and carbon monoxide detectors were tested and in proper working order. Fire extinguishers are fully charged. Room temperatures are maintained at 76 degrees F. The hot water temperature was tested and measured at 106 degrees F. All sinks, showers and toilets were in working order. No more than 2 children share a bedroom. All beds are in good repair; equipped with good springs, clean mattresses and pillows. Adequate supply of beddings and linens were observed. Emergency exits are free from obstruction. Overall, the facility is clean, safe, sanitary and in good repair. Operations Facility maintains a register of clients and the register is available upon request. The board of directors regularly conduct meetings to review and discuss the STRTP's operation. The facility has developed, maintained and implemented written complaint procedures. Emergency Intervention Documentation of emergency intervention training for staff is on file. The facility maintains a monthly restraint log which will be submitted bi-annually to the Department. Disaster Preparedness Plan Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts disaster drill at least quarterly for each shift. Facility maintains an emergency and disaster plan, register of clients, Needs and Services Plan for each client, medication records, and contact information for each client's responsible party and physician. Core/Therapeutic Services Facility provides core services and supports to children and non-minor dependents as appropriate or necessary that are trauma informed, culturally relevant, age and developmentally appropriate and include the following: Medi-Cal specialty mental health services; transition support services; educational and physical, behavioral, and mental health supports; activities to support children and non-minor dependents and services to achieve permanency. Client Records LPAs reviewed two (2) client records. Client records are available to the licensing agency to inspect, audit and copy upon demand. Client records contain required information including, but not limited to, consent forms, court orders, needs and services plan, medical assessment; safeguards for cash resources, personal property and valuables; education records; personal rights forms; removal/discipline/complaints form and medication administration records. Staff Records LPAs reviewed three (3) staff records. All staff have been subjected to criminal records review and have been fingerprinted and cleared with DOJ, FBI and CACI. Documentation of the required education and experience requirements are maintained in the personnel file. Documentation of staff training are on file. During records review, LPAs did not find health screening forms for S2 and S3. LPAs interviewed three (3) staff members. LPAs were unable to interview the two (2) clients due to both are in the hospital at the time of inspection. One (1) Type B deficiency citation was issued during today's inspection, see LIC809D. An exit interview was conducted, and a signed copy of this report, LIC809D, LIC811 and appeal rights were provided to the facility representative..

met_with: Thandi Smith


summary: Facility Evaluation

raw_content:
Narrative:
On 11/28/23 at 12: PM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced case management inspection at the above facility and met with Supervising Facility Manager, Danielle Council. The purpose of the inspection is to follow up on an Unusual Incident Report (UIR) that was received by the Department on 11/17/23. The incident indicated that staff (S1) found a pill on the office floor (refer to Confidential Names List LIC811 dated 11/28/23). Based on the investigation conducted by Supervising Facility Manager (S2), the pill found on the floor belonged to client C1. S2 was able to confirm that the pill was a medication that C1 is scheduled to take at nighttime. S2 also confirmed that C1 did not miss her medication the night before. The investigation also indicated that staff S1, who assisted C1 in the administration of medication the night before, accidentally poked a hole in the bubble pack with her nails which resulted to the pill falling onto the floor. Due to this incident, S2 reminded all staff to ensure that everyone follows the correct protocol in the administration of medications. LPA Silva issued a Technical Advisory (TA), see LIC9102. This TA is not a citation but is issued to provide assistance and/or best practices. No further follow-up is needed. An exit interview was conducted, and a copy of this report was provided to the facility representative.

met_with: Danielle Council


summary: Facility Evaluation

raw_content:
Narrative:
On 01/18/24 at 9: AM, Licensing Program Analysts (LPAs) Pamela Silva and Juliet Robles conducted an unannounced Annual Inspection at the facility. LPAs met with Cindi Bertrand, Administrator. This STRTP is licensed to serve up to six (6) ambulatory children ages 7-17 years of age. The facility also provides services to non-minor dependents pursuant to W&I Code 16501.1 (C)(1). There is one (1) minor currently in placement. The facility is a single-story home located in a residential area. There are no bodies of water on the premises. At 9: AM, LPAs conducted a walk-through of the entire facility. Physical Plant The license, facility sketch, Personal Rights, Emergency Disaster form, Complaints poster, Foster Youth Bill of Rights, Complaints/Grievance policy, emergency phone numbers and menus are posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions and sharps are kept inaccessible in a locked closet in the hallway. Facility has non-perishable food for at least one week and perishable food for at least two days. Medications are centrally stored in a locked cabinet in the staff office. Smoke and carbon monoxide detectors were tested and in proper working order. Fire extinguishers are fully charged. Room temperatures are maintained at 76 degrees F. The hot water temperature was tested and measured at 108 degrees F. All sinks, showers and toilets were in working order. All beds are in good repair; equipped with good springs, clean mattresses and pillows. Adequate supply of beddings and linens were observed. Emergency exits are free from obstruction. Overall, the facility is clean, safe, sanitary and in good repair. Operations Facility maintains a register of clients and the register is available upon request. The board of directors regularly conducts meetings to review and discuss the STRTP's operation. The facility has developed, maintained and implemented written complaint procedures. Emergency Intervention Documentation of emergency intervention training for staff is on file.The facility maintains a monthly restraint log which will be submitted bi-annually to the Department. Disaster Preparedness Plan Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts disaster drill at least quarterly for each shift. Facility maintains an emergency and disaster plan, register of clients, Needs and Services Plan for each client, medication records, and contact information for each client's responsible party and physician. Core/Therapeutic Services Facility provides core services and supports to children and non-minor dependents as appropriate or necessary that are trauma informed, culturally relevant, age and developmentally appropriate and include the following: Medi-Cal specialty mental health services; transition support services; educational and physical, behavioral, and mental health supports; activities to support children and non-minor dependents and services to achieve permanency. Client Records LPAs reviewed one (1) client file. Client records are available to the licensing agency to inspect, audit and copy upon demand. Client file contains required information including, but not limited to, consent forms, court orders, needs and services plan, medical assessment; safeguards for cash resources, personal property and valuables; education records; personal rights forms; removal/discipline/complaints form and medication administration records. Staff Records LPAs reviewed three (3) staff records. All staff have been subjected to criminal records review and have been fingerprinted and cleared with DOJ, FBI and CACI. Documentation of the required education and experience requirements is maintained in the personnel file. Documentation of staff training is on file. LPAs interviewed two (2) staff members. One (1) client was unavailable for interview at the time of inspection due to being in school. No deficiency citation is being issued during today's inspection. An exit interview was conducted, and a signed copy of this report was provided to the Administrator.

met_with: Cindi Bertrand


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Juliet Robles, and Pamela Silva on 01/18/24 at 9: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Cindi Bertrand, Administrator, Danielle Council, Supervising Facility Manager and inspected the facility inside and out. LPAs reviewed one (1) of child's records and three (3) of staff personnel files on site at the facility. LPAs reviewed one (1) of child's psychotropic medications and medication records. LPAs interviewed three (3) of staff on site to discuss the facility's policies and procedures of operation. LPA interviewed 0 of child currently prescribed psychotropic medication. Child was at school and LPA will conduct interview at a later date. LPAs provided a copy of this licensing report to Administrator, Cindi Bertrand. No deficiencies are being cited at this time. LPAs conducted exit interview with Administrator, Cindi Bertrand.


summary: Facility Evaluation

raw_content:
Narrative:
On Thursday April 24, 2025, at 11:05AM, Licensing Program Analyst (LPA) Humberto Flores, conducted a Case Management inspection at Beloved Ones Short Term Therapeutic Program (STRTP) and met with Supervisor Facility Manager Serina Lindsay and Administrator, Jeanne Fletcher. The purpose of the inspection is to address the below deficiencies found. A file review inspection was conducted for employees Ref #1 (S1), Ref #2 (S2), Ref #3 (S3) and Ref #4 (S4) (see Confidential Names form LIC811 dated 04/24/2025). During the inspection LPA Flores observed that S1 and S2 were not associated to the STRTP prior working at the facility. An immediate assessment of civil penalties of one hundred dollars ($100) per violation for a maximum of 5 days was assessed, for a total of $1000 (one thousand dollars). This is a violation of California Code of Regulations (CCR), Title 22, Division 6, Section Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) cont.# During this inspection and file review it was observed that S3 did not have a Cardiopulmonary Resuscitation (CPR) and First Aid Training Certificate. This is a violation of the below regulations: - Interim Licensing Standards (ILS), Version 5, Section 87065.1 (b)(8)(A) (8) Facility manager training is in addition to first aid and CPR training, and other training as required in Section 87095.65. (A) Completion of cardiopulmonary resuscitation (CPR) and first aid training shall be demonstrated by current and valid CPR and first aid cards issued by the American Red Cross, the American Heart Association, a training program approved by the State Emergency Medical Services Authority pursuant to Health and Safety Code Section 1797.191, or from an accredited college or university. Two (2) citations type A were issued. These are violations of the regulations and the Health and Safety Code that, if not corrected, have a direct and immediate risk to the health, safety or personal rights of those in care. A copy of this report, citation page, appeal rights, and LIC811 was provided, via email, to the STRTP representative. Exit interview conducted.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Timika Martin, Juliet Robles and Ashley Ruacho on 10/23/25 at 9: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Jeanne Fletcher, Administrator and inspected the facility inside and out. LPAs reviewed one (1) of children's records and three (3) of staff personnel files on site at the facility. LPAs reviewed one (1) of children's psychotropic medications and medication records. LPAs interviewed two (2) staff on site to discuss the facility's policies and procedures of operation. LPAs interviewed zero (0) children currently prescribed psychotropic medication. LPA Martin will attempt to interview children at a later time. During the inspection the LPAs observed a deficiency (see attached 809D). A Technical Advisory was issued (see LIC 9102). Plan of correction was discussed and appeal rights were provided. LPAs conducted exit interview and provided a copy of this licensing report to Administrator, Jeanne Fletcher.

met_with: Jeanne Fletcher, Adminstrator


summary: Facility Evaluation

raw_content:
Narrative:
On 11/05/25 at 9: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced case management inspection at the above facility and met with Administrator, Jeanne Fletcher. The purpose of the inspection is to follow up on a Special Incident Report (SIR) received by the Department on 10/27/25. The incident indicated medication mismanagement by staff S1 that occurred on 10/24/25 (refer to Confidential Names List LIC811 dated 11/05/25). LPA Silva reviewed the SIR and conducted a telephone interview with staff S2 via telephone on 10/29/25. Based on review of SIR and staff interview, staff S1 administered medication (M1) to client C1 twice in the evening of 10/24/25. Review of medication (M1) prescription indicated that it should be taken once during the evening. That evening, S1 should have administered another prescription medication instead of medication M1. During the inspection, LPA Silva reviewed S1's file regarding medication training and staff qualifications. S1's file showed medication administration training prior to assisting clients with medication administration. Based on the information gathered, a deficiency citation on Health and Safety Code 150706(b)(1) is being issued, see LIC809D. An exit interview was conducted, and a copy of this report and appeals right was provided to Ms. Fletcher.

met_with: Jeanne Fletcher


summary: Facility Evaluation

raw_content:
Narrative:
On 09/21/23 at 12: PM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced case management inspection at the above facility and met with Supervising Facility Manager Tere Paredes, on behalf of Supervising Facility Manager Danielle Council. The purpose of the inspection is to follow up an incident report regarding client's (C1) medication refusal (refer to Confidential Names List LIC811 dated 09/21/23). LPA Silva received an Unusual Incident Report (UIR) of medication refusal for C1 on 09/20/23. However, the incident occurred on 09/02/23 but was only reported to the Department on 09/20/23. This is in violation of Title Division Chapter Article 6, 80061(b)(1)(E) on Reporting Requirements. A deficiency citation is being issued, see LIC809D. Exit interview conducted. A copy of this report, LIC809D, LIC 811 and appeal rights were provided to the facility representative.

met_with: Tere Paredes


summary: Facility Evaluation

raw_content:
Narrative:
On 06/25/24 at 9: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced case management inspection at the above facility and met with Supervising Facility Manager, Serina Lindsay. The purpose of the inspection is to follow up on multiple incidents which were reported late to the Department. Several Unusual Incident Reports (UIR) were submitted to the Department on 05/24/24. Based on LPA review of these UIRs, there were six (6) incidents that occurred on 05/18/24, one (1) on 05/13/24, one (1) on 05/15/24 and one (1) on 05/21/24. LPA found no 24-hour initial notifications reported to the Department on all of the nine (9) incidents. This is in violation of Title Division Chapter Article 6, 80061(b)(1)(E) on Reporting Requirements. A deficiency citation is being issued, see LIC809D. A previous violation of California Code of Regulations 80061(b)(1)(E ) was cited on 09/21/23. Based upon repeating the same violation within a 12-month period, it is determined that an immediate civil penalty of $250 be assessed (see LIC421FC). Exit interview conducted. A copy of this report and appeal rights were provided to Ms. Lindsay.

met_with: Serina Lindsay


summary: Facility Evaluation

raw_content:
Narrative:
On March 10, 2026 at 8: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced Annual Random inspection at the above facility and met with Jeanne Fletcher, Administrator. This STRTP is licensed to serve up to two (2) children ages 7-17 years of age. The facility also provides services to non-minor dependents pursuant to W&I Code 16501.1 (C)(1). There is one (1) minor currently in placement LPA obtained and reviewed the following updated documentation: · LIC Personnel, Client Roster · LIC C Emergency Disaster Plan/Mass Casualty Plan · Current Board Meeting Minutes · Continuous Quality Improvement Report The Compliance and Regulatory Enforcement (CARE) Tool was used by the LPA during today's inspection which consisted of a review of the following domains: Physical Plant, Operations, Disaster Preparedness Plan, Staff Files, Client Files, Core Therapeutic Services and Emergency Intervention Plan. LPA conducted a physical plant inspection. This facility is a one-story 2-bedroom home with two (2) bathrooms. There are no bodies of water on the premises. There are no firearms or ammunition in the facility. Overall, the facility is clean, sanitary and in good condition. LPA reviewed one (1) client records and three (3) staff records. All staff have been subjected to criminal records review and have been fingerprinted and cleared with DOJ, FBI and CACI. Documentation of initial and annual staff training, including training on emergency intervention, is on file. Two (2) staff members were interviewed. No client was interviewed as the client refused to be interviewed. No deficiencies were issued during today's inspection. One (1) Technical Advisory was issued, see LIC9102TV. An exit interview was conducted and a signed copy of this report was provided to the Administrator


facility_name: BELOVED ONES 3

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Confidential statements obtained during the investigation were unable to corroborate the allegations as details obtained provided inconsistencies which did not support the allegations. The county placing agency social worker provided confidential information regarding the client which did not support the allegations. In addition, the client was unable to be interviewed due to being runaway status with her whereabouts unknown. Facility staff denied the allegations. Documentation of pre-placement and placement indicate that Client has a history of running into traffic and putting herself at risk. Records indicate that that crisis intervention was performed during de-escalation and records indicate incidents that took place during placement and services that were provided and not followed by the client. Based on the information gathered, the allegations are unsubstantiated as the preponderance of evidence to prove the allegations was not met although the allegations may have happened or are valid. A copy of this report, Confidential Names Form and Appeal Rights were provided to the facility representative. There were no deficiencies cited during this inspection.

Investigation Findings:
13On January 24, 2024, at 11: AM, Licensing Program Analyst (LPA) Claudia Portillo conducted a follow-up inspection to deliver the findings of a complaint investigation concerning the allegation above. LPA Portillo discussed the findings with the facility representative named above. During the course of the investigation, LPA Portillo interviewed the complainant and County Social Worker on 10/13/23, facility staff on 10/20/23 and 1/22/24 (see Confidential Names Form dated January 24, 2024). LPA Portillo reviewed documents including the placing agency service reports, Mental Health Assessment, CFT Notes, Needs and Services Plans, incident reports, and personnel files. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Claudia Portillo LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELOVED ONES 3FACILITY NUMBER: VISIT DATE: 01/24/2024

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

met_with: Cory Jackson, Facility Manager

complaint_status: unsubstantiated


raw_content:
Investigation Findings:
13On June 25, 2024, at 11: AM, Licensing Program Analyst (LPA) Winston Moroney conducted a complaint inspection at the above Short-Term Residential Therapeutic Program (STRTP) and met with the Facility Manager Cory Jackson. The inspection aimed to deliver the finding(s) regarding the complaint allegation(s). On April 23, 2024, the Community Care Licensing Division of the California Department of Social Services received a complaint from the Centralized Complaint and Information Bureau (CCIB) with the following allegation(s): The facility staff is not arranging transportation for youth as needed. This LPA conducted the investigation of the above allegation(s) and it consisted of but was not limited to a review of records, including the client's needs and services plans, medical records, and interviews with the two staff members (S1) on 5/2/24, S2 on 5/2/24, 1 client (C1) on 5/2/24, and the CSW on 5/22/24. (Reference Confidential Names Form LIC 811, dated June 25, 2024). The Following Allegation(s) were reported: 1. The facility staff is not arranging transportation for youth as needed. Staff members S1 and S2 denied the accusation by clarifying that during the alleged incident, C1 had called from school requesting to be picked up because of feeling unwell. They explained that they received three calls, two of which were distorted with static and cutting in and out, making it challenging to understand the message. On the third call, they identified C1's voice but still struggled to comprehend due to the background noise. S1 was then sent to the school to conduct further investigation. Upon arrival, S1 was informed that C1 was indeed unwell and required assistance returning to the facility. S1 reassured the school that it would be taken care of but had to go back to the facility to get the facility car as personal vehicles were not permitted for client transportation. S1 informed school staff that they would return within fifteen minutes to accompany C1 back to the facility. The information gathered from C1 confirmed the aforementioned and additionally mentioned that they did not encounter any problems with transportation and that it was the only instance. Details obtained from the CSW revealed that during their interactions with C1, no concerns were observed, and C1 did not face any transportation issues. Furthermore, it was disclosed that the facility staff are highly attentive and supportive towards their clients. Therefore, based on the information received, the above allegation(s) is determined to be unsubstantiated. Although the allegation(s) may have happened is are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the allegations are found to be unsubstantiated. Appeal Rights were provided and discussed with the Foster Family Agency. There are no deficiencies to be cited at this time. An exit interview was conducted and a copy of the report along with the (LIC 811) was left with the STRTP Facility Manager. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Winston Moroney LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Cory Jackson - Facility Manager


raw_content:
Narrative:
The Following Allegation(s) were reported: It was reported that on April 7, 2025, a staff member (S3) allegedly struck C1 with a shoe on their buttocks and also hit them in the eye after C1 touched a floral decoration that S3 had recently made for the facility. The staff members (S1, S2, S3, S4, and S5) denied these allegations, asserting that all staff are trained in trauma-informed care practices, which emphasize de-escalation, empathy, and non-violent communication. These practices aim to prevent retraumatization and to ensure the emotional and physical safety of clients. Additionally, several staff members indicated that each staff member has undergone Pro-Act training, a comprehensive program that details safe and ethical physical intervention techniques. Such techniques are employed only as a last resort when there is an imminent risk of harm to the client or others, utilizing the least restrictive measures necessary to maintain safety. The staff members stated that no physical intervention was needed or performed during the incident. They maintain that C1 was verbally redirected and that no physical contact took place between S3 and C1. C2 refuted the claim, stating that they have never witnessed or heard of any employee hitting or mistreating any client. C2 emphasized that the staff is highly supportive and offers everything necessary to guarantee success with their program. The statement obtained from C1 did not corroborate the above allegations due to C1 providing contradicting information to various interviewers, including Law Enforcement, Kern County (SSP), and LPA. Additionally, the statement obtained from the Kern County SSP confirmed that they have no objections or concerns regarding the quality of care and supervision provided by the facility staff. Therefore, based on the information received, the above allegation(s) are determined to be unsubstantiated. Although the allegation(s) may have happened are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred; therefore, the allegations are found to be unsubstantiated. Appeal Rights were provided and discussed with the Foster Family Agency. There are no deficiencies to be cited at this time. An exit interview was conducted and a copy of the report along with the (LIC 811) was left with the STRTP Facility Manager.

Investigation Findings:
13On August 8, 2025, at 1: PM, Licensing Program Analyst (LPA) Winston Moroney conducted a complaint inspection at the above Short-Term Residential Therapeutic Program (STRTP) and met with the Facility Manager, Edward Hillman. The inspection aimed to deliver the finding(s) regarding the complaint allegation(s). On April 7, 2025, the Community Care Licensing Division of the California Department of Social Services received a complaint from the Centralized Complaint and Information Bureau (CCIB) with the following allegation(s): The staff hit a minor in care, resulting in bruising; The staff used inappropriate forms of discipline. This LPA conducted the investigation of the above allegation(s) and it consisted of but was not limited to a review of records, including the client's needs and services plans, medical records, SIR's and interviews with the five staff members (S1, S2) on 4/10/25, (S3) on 4/24/25, (S4, S5) on 5/23/25, 2 of 2 clients (C1, C2) on 4/10/25, and the SSP on 1/31/24. Reference Confidential Names Form LIC 811, dated August 8, 2025. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Winston Moroney LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELOVED ONES 3FACILITY NUMBER: VISIT DATE: 08/08/2025

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

met_with: Edward Hillman - Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On February 15, 2022, Humberto Flores, Licensing Program Analyst (LPA), conducted an announced Case Management Inspection at Beloved Ones Short Term Residential Therapeutic Program (STRTP) and met with Jessica Hatley. The purpose of the inspection was to verify that the facility meets the requirements for a capacity increase, previously requested, to six (6) children. Currently the facility licensed capacity is one (1) child. LPA Flores inspected the facility and observed that there are 2 beds with mattresses, pillows and bed sheets in room #1, room #2 and room #3. There is a closet in each room with enough space to store clothes and shoes. A copy of the facility sketch was provided upon request. LPA Flores observed that the STRTP meets the requirements to hold a licensed capacity of six (6) children. No further inspection is needed. A copy of this report was provided to the facility representative. Exit interview conducted.


summary: Facility Evaluation

raw_content:
Narrative:
On May 09, 2022, 10:50AM, Licensing Program Analyst (LPAS) Humberto Flores, conducted an unannounced Annual Inspection at Beloved Ones Short Term Therapeutic Residential Treatment (STRTP) and met with Cynthia Bertrand. LPA Flores stated the purpose of the inspection to the STRTP representative. During the inspection a copy of the Register of Facility Clients and Personnel Report was provided upon request. The following topics were inspected: PHYSICAL PLANT: A tour of the facility was conducted, along with Cynthia Bertrand. The License is placed in a prominent place, in the reception are of the facility. Children's foster rights were posted. LPA Flores observed that the facility is clean, safe, sanitary and in good repair. The passageways are unobstructed. There is no swimming pool or body of water. The disinfectants and cleaning solutions were stored away from the kitchen areas, food preparation areas to the children. The food is safe and of the quality and the quantity necessary to meet the needs of the clients. # Each meal meets at least 1/3 of the recommended in the USDA Basic Food Group Plan-Daily Food Guide. Supplies of staples non-perishable foods for one week and perishable foods for two days are maintained in the facility. Currently no client is taking psychotropic medication. The temperature in the rooms that clients occupy are maintained between 68 and 85 degrees (F). The hot water temperature was at 119.7 degrees (F). Emergency Intervention Plan: LPA Flores reviewed the program statement and PROACT instruction manual and identified the training that is provided for all staff. The staff receive on-going training to maintain certification. A monthly log is utilized to document manual restraints. According to the STRTP representative, there has been no restraint. Disaster Preparedness Plan: LPA Flores reviewed the disaster and mass casualty plan and other provisions by reviewing the program statement. The facility conducts monthly fire and emergency evacuation drills. Drills are documented and kept in the facility for at least one year. CLIENT RECORDS: LPA Flores reviewed the one (1) client file records. Needs and services is trauma informed, culturally relevant, and age and developmentally appropriate and identified the child's needs: reason for placement, education, personal care and grooming, ability to manage money, visitation information, mental health services and placement information. # Copy of the Identification Card, Consent Forms for Medical and Dental Treatment. The STRTP representative disclosed that the appointment for the Health Screening is on 5/24/2022 and a Tuberculosis Test will be obtained too. CORE THERAPEUTIC SERVICES: During the inspection review, LPA Flores was able to see that the facility is providing the Short-Term Therapeutic Program (STRTP) core services and support to the individuals in placement. The facility has trauma informed, culturally relevant, age, and developmentally appropriate. The facility is also providing trauma informed core services through agreements with other agencies. OPERATIONAL REQUIREMENTS: During the inspection review, LPA Flores observed the facility maintained an updated roster of the clients with pertinent information. The facility administrator and manager are the responsible and capable staff for communicating with emergency personnel in the facility. The facility has developed, maintained and implemented written complaint procedures STAFFING RECORDS: During the inspection review, LPA Humberto inspected one (1) staff files and verified that all facility staff was subject to criminal records review, fingerprinted and cleared DOJ, FBI and CACI, training hours. # LPA Flores observed that Facility Manager Staff Ref #1 (S1) (see Confidential Names form LIC811 dated 05/09/2022) did not meet the requirements of two years of full-time experience, or its equivalent, working with the population to be served. This is a violation of Interim Licensing Standards (ILS), Section 87065 (f)(1)(B): f) The licensee shall designate at least one facility manager to be present at the facility at all times when one or more children are present: (1) The facility manager shall meet one of the following requirements prior to employment: (B)Two years of full-time experience, or its equivalent, working with the population to be served, or equivalent education or experience, as determined by CDSS. 1. Experience shall be verified as having been performed as a paid or volunteer staff person whose duties required direct supervision and care of the population served. This is a violation of the regulations and the Health and Safety Code that, without correction, could become an immediate risk to the health, safety or personal rights of clients, or record keeping violation that would impact the care of clients and/or protection of their resources, or a violation that would impact those services required to meet clients' needs. A type B citation was issued. # A search and review of Licensing Information System (LIS) was conducted during the inspection. All employees have criminal record clearance with the Department of Justice (DOJ, Federal Bureau of Investigation (FBI) and Child Abuse Central Index (CACI) and are associated to the STRTP in the Licensing Information System (LIS). A copy of this report, LIC811s and LIC809D and appeal rights was provided to the STRTP representative. Exit interview conducted.

met_with: Cynthia Bertrand, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On September 22, 2022, at 10:35AM, Humberto Flores, Licensing Program Analyst (LPA), conducted an unannounced Case Management Inspection, at Beloved Ones Short Therapeutic Residential Treatment Program (STRTP) and met with Cynthia Bertrand. The purpose of the inspection was to gather information about the below incident reported via Special Incident Report (SIR). The STRTP reported that on 02/27/2022, Child Ref #1 (C1) (see Confidential Names form LIC811), was transported to a medical facility and diagnosed with Diabetic Ketoacidosis due to not taking any insulin for over 48 hours (hrs). C1 was prescribed, and taking, insulin. LPA Flores investigated the incident and interviewed Cynthia Bertrand and spoke with Thandi Smith over the phone. LPA Flores requested copies from C1's file, and copies were made upon request. The SIRs and statements provided revealed that on 02/25/2022, around 2:29PM, ran away from the facility and went to a friend's house until 02/27/2022 that he was located by facility staff. On 02/25/2022, the STRTP decided to conduct an emergency removal on C1 due to C1's erratic and aggressive behavior. C1 did not return to the STRTP after he was discharged from the medical institution. cont.# No further inspection is needed. A copy of this report and LIC811 was provided to the facility representative. Exit interview conducted.


summary: Facility Evaluation

raw_content:
Narrative:
On 03/09/23 at 11: AM, Licensing Program Analysts (LPAs) Pamela Silva and Ashley Ruacho conducted an unannounced Annual Inspection at the facility. LPAs met with Cindi Bertrand, Administrator. The facility currently has a provisional Short Term Residential Therapeutic Program (STRTP) license. The STRTP's Mental Health Program Application is pending approval. This STRTP is licensed to serve up to six (6) ambulatory children ages 7-17 years of age. The facility also provides services to non-minor dependents pursuant to W&I Code 16501.1 (C)(1). There is one (1) minor and one (1) non-minor dependent currently in placement. The facility is a single-story home located in a residential area. There are no bodies of water in the premises. LPAs conducted a walk-through of the entire facility. Physical Plant The license, facility sketch, Personal Rights, Emergency Disaster form, Complaints poster, Foster Youth Bill of Rights, Complaints/Grievance policy, emergency phone numbers and menus are posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions and sharps are kept inaccessible in a locked closet in the hallway. Facility has non-perishable food for at least one week and perishable food for at least two days. Medications are centrally stored in a locked cabinet in the staff office. Smoke and carbon monoxide detectors were tested and in proper working order. Fire extinguishers are fully charged. Room temperatures are maintained at 76 degrees F. The hot water temperature was tested and is within standard range. All sinks, showers and toilets were in working order. No more than 2 children share a bedroom. All beds are in good repair; equipped with good springs, clean mattresses and pillows. Adequate supply of beddings and linens were observed. Emergency exits are free from obstruction. Overall, the facility is clean, safe, sanitary and in good repair. Operations Facility maintains a register of clients and the register is available upon request. The board of directors regularly conduct meetings to review and discuss the STRTP's operation. The facility has developed, maintained and implemented written complaint procedures. Emergency Intervention Documentation of emergency intervention training for staff is on file. The facility maintains a monthly restraint log which will be submitted bi-annually to the Department. According to the Administrator, there have been no manual restraints. Disaster Preparedness Plan Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts disaster drill at least quarterly for each shift. Facility maintains an emergency and disaster plan, register of clients, Needs and Services Plan for each client, medication records, and contact information for each client's responsible party and physician. Core/Therapeutic Services Facility provides core services and supports to children and non-minor dependents as appropriate or necessary that are trauma informed, culturally relevant, age and developmentally appropriate and include the following: Medi-Cal specialty mental health services; transition support services; educational and physical, behavioral, and mental health supports; activities to support children and non-minor dependents and services to achieve permanency. Client Records LPAs reviewed two (2) client records. Client records are available to the licensing agency to inspect, audit and copy upon demand. Client records contain required information including, but not limited to, consent forms, court orders, needs and services plan, medical assessment; safeguards for cash resources, personal property and valuables; education records; personal rights forms; removal/discipline/complaints form and medication administration records. Staff Records LPAs reviewed two (2) staff records. All staff have been subjected to criminal records review and have been fingerprinted and cleared with DOJ, FBI and CACI. Documentation of the required education and experience requirements are maintained in the personnel file. Documentation of staff training are on file. LPAs interviewed two (2) staff members. LPAs were unable to interview the two (2) clients due to one client's refusal and one client is out on a community day pass. During the inspection, LPAs were informed about a car accident that occurred on 03/07/23. One client was in the car when the accident happened. There were no injuries to the client. The staff driving the vehicle was taken to the hospital and was later discharged. The incident was not reported to the Department. A deficiency citation is being issued, see LIC809D. An exit interview was conducted, and a signed copy of this report, LIC809D, LIC811 and appeal rights were provided to the facility representative..


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Pamela Silva on March 7, 2024 at 9: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA met with Jeanne Fletcher, Interim Administrator, and inspected the facility inside and out. There are no children currently taking psychotropic medication at the facility. LPA reviewed zero (0) of child's records and three (3) of staff personnel files on site at the facility. LPA reviewed zero (0) of child's psychotropic medications and medication records. LPA interviewed two (2) of staff on site to discuss the facility's policies and procedures of operation. No child interview was conducted during this inspection due to no children is currently taking psychotropic medication. LPA provided a copy of this licensing report to Jeanne Fletcher, Interim Administrator. No deficiencies are being cited at this time. LPA conducted exit interview with the Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On 03/07/24 at 11: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced case management (CM) inspection at the above facility and met with Interim Administrator, Jeanne Fletcher. CM #1: This case management is to follow-up on how the facility is accepting clients. In July 2023, the facility accepted a pregnant client. The facility's program statement does not include pregnant teens in their population to be served. Per LPA's telephone conversation with the facility's Director, Thandi Smith, the client was accepted into the facility as an emergency placement. The Director stated that his understanding is that the facility, as STRTP of 1 or 2, can accept generalized population for as long as they have high risk behaviors. This issue has been discussed in a telephone meeting conducted on 02/06/24 between LPA and the facility's director. A Technical Violation (TV) is being issued, see LIC9102TV. CM #2: On 07/11/23, a Law Enforcement Contact Report indicated that client C1 had access to the laundry detergent from the company vehicle. Based on the review of the incident report and an interview with staff S1, the laundry detergent was among other things S1 and C1 shopped for before the incident happened. As soon as they reached the facility, C1 got off the vehicle and walked in the middle of the street while moving vehicles were driving by. Due to safety concerns, S1 had to get in the vehicle again and followed C1 before he could put the detergent inside the facility and away from clients. S1 was able to get C1 back into the vehicle and this was when C1 gained access to the detergent. Due to S1's action to prioritize C1's safety first, no deficiency citation is being issued. No further follow-up is needed. An exit interview was conducted, and a copy of this report was provided to the facility representative.


summary: Facility Evaluation

raw_content:
Narrative:
On 03/12/25 at 8: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced Annual Inspection and met with Jeanne Fletcher, Administrator. This STRTP is licensed to serve children ages 7-17 years of age. The facility also provides services to non-minor dependents pursuant to W&I Code 16501.1 (C)(1). There are two (2) minors currently in placement. The facility is a single-story home located in a residential area. There are no bodies of water in the premises. LPA conducted a walk-through of the entire facility. Physical Plant The license, facility sketch, Personal Rights, Emergency Disaster form, Complaints poster, Foster Youth Bill of Rights, Complaints/Grievance policy, emergency phone numbers and menus are posted in a prominent, publicly accessible location in the facility. Disinfectants, cleaning solutions and sharps are kept inaccessible in a locked closet in the hallway. Facility has non-perishable food for at least one week and perishable food for at least two days. Medications are centrally stored in a locked cabinet in the staff office. Smoke and carbon monoxide detectors were tested and in proper working order. Fire extinguishers are fully charged. Room temperatures are maintained at 76 degrees F. The hot water temperature was tested and was measured at 112 degrees F. All sinks, showers and toilets were in working order. No more than 2 children share a bedroom. All beds are in good repair; equipped with good springs, clean mattresses and pillows. Emergency exits are free from obstruction. Overall, the facility is clean, safe, sanitary and in good repair. Operations Facility maintains a register of clients and the register is available upon request. The board of directors regularly conduct meetings to review and discuss the STRTP's operation. The facility has developed, maintained and implemented written complaint procedures. Emergency Intervention Documentation of emergency intervention training for staff is on file. The facility maintains a monthly restraint log which will be submitted bi-annually to the Department. Disaster Preparedness Plan Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts disaster drill at least quarterly for each shift. Facility maintains an emergency and disaster plan, register of clients, Needs and Services Plan for each client, medication records, and contact information for each client's responsible party and physician. Core/Therapeutic Services Facility provides core services and supports to children and non-minor dependents as appropriate or necessary that are trauma informed, culturally relevant, age and developmentally appropriate and include the following: Medi-Cal specialty mental health services; transition support services; educational and physical, behavioral, and mental health supports; activities to support children and non-minor dependents and services to achieve permanency. Client Records LPA reviewed two (2) client records. Client records are available to the licensing agency to inspect, audit and copy upon demand. Client records contain required information including, but not limited to, consent forms, court orders, needs and services plan, safeguards for cash resources, personal property and valuables, education records, personal rights forms, removal/discipline/complaints form and medication administration records. Staff Records LPA reviewed three (3) staff records. All staff have been subjected to criminal records review and have been fingerprinted and cleared with DOJ, FBI and CACI. Documentation of the required education and experience requirements are maintained in the personnel file. Documentation of staff training are on file. LPA interviewed two (2) staff members. The two (2) clients were unavailable for interview due to being in school at the time of inspection. LPA will attempt to interview clients at a later time. Technical Advisories were issued, see LIC9102TAs and LIC9102TV. An exit interview was conducted, and a signed copy of this report, LIC9102s and LIC811 were provided to the Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On Tuesday April 29, 2025, at 12:40PM, Licensing Program Analyst (LPA) Humberto Flores, conducted a Case Management inspection at Beloved Ones Short Term Residential Therapeutic Program (STRTP). The purpose of the inspection was to conduct a criminal record review of all staff working at the facility. LPA Flores obtained a copy of the LIC Personnel Report and conducted a search and review in Guardian. The information revealed that all twenty six (26) employees listed in the LIC500 dated February 26, 2025, have a criminal record clearance from the Department of Justice (DOJ), Federal Bureau of Investigation (FBI) and Child Abuse Central Index (CACI). No further inspection is needed. No citation was issued. A copy of this report was provided, via email, to the STRTP representative. Exit interview conducted.


summary: Facility Evaluation

raw_content:
Narrative:
On June 18, 2025 at 10: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced case management inspection at the above facility and met with Administrator, Jeanne Fletcher. The purpose of the inspection is to follow up on a referral or incident received by Department on 06/09/25 regarding possible personal rights violation. LPA Silva conducted a tour of the facility. LPA interviewed child C1. Copies of Client Roster, LIC Personnel Report, Staff Contact List and the child's Needs and Services Plan were requested. Further follow-up is needed to complete this case management. No deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was provided to the Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On July 1, 2025 at 9: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced case management inspection at the above facility and met with Administrator, Jeanne Fletcher. The purpose of the inspection is to follow up on a referral and an incident report received by Department on 06/09/25 regarding possible personal rights violation. LPA Silva conducted telephone interviews with 3 staff members on 06/16/25, child's (C1) County Social Worker (CSW) and Emergency Response Social Services Practitioner (SSP) on 06/17/25. LPA interviewed child C1 and Administrator on site, and conducted a tour of the facility on 06/18/25 (refer to Confidential List LIC811 dated 07/01/25). C1's Needs and Services Plan were reviewed by LPA. Two (2) staff members who were present in the facility at the time of the incident denied that staff S2 hit C1 back while C1 was having a tantrum and was attacking staff. Two (2) staff also denied that S2 picked up C1 from the floor by his leg and took him to his room. Interviews revealed that after C1 dropped himself to the floor while having a tantrum, S2 and S3 walked C1 to his room, with one staff holding C1 under his right arm and the other staff holding C1 under his left arm. During an interview with child C1, C1 denied that any facility staff hits him. C1 also denied to SSP that a staff hit him during the alleged incident. C1 stated that he feels safe at the facility and has no concerns regarding staff. CSW has no safety concerns regarding the facility nor any staff. During interviews conducted, it was disclosed that C1 has nothing in his room, but a mattress and that C1's room has no door. According to the Administrator, all things except the mattress were removed from C1's room for his safety and the safety of staff as well due to C1 uses things in his room as a weapon to assault or attack staff. In an interview with C1's CSW, she is aware that everything but the mattress, were removed from C1's room for safety concerns. CSW confirmed to LPA Silva that her supervisor was okay with the removal of things and the door from C1's bedroom due to safety concerns for C1 and others as well. However, CSW Supervisor stated that no rough pieces should be sticking out of the walls and door frame to prevent injury to C1. During the facility tour, LPA Silva observed that there were some rough wood pieces on the door frame coming out from where the hinges were. LPA advised Administrator to patch and smoothen the rough areas of the door frame, and Administrator complied the same day. During today's inspection, LPA observed that C1's door was re-installed. Things in C1's room that are not considered as safety hazards like bed frame, TV, curtains, etc., are back but were installed more securely. No further follow-up is needed for this case management due to no personal rights violation were found. No deficiency citation was issued during today's inspection. An exit interview was conducted, and a copy of this report was provided to the Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Juliet Robles, Timika Martin and Ashley Ruacho on 10/23/25 at 12: PM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs met with Jeanne Fletcher, Administrator, and inspected the facility inside and out. LPAs reviewed 1 of child's records and 3 of staff personnel files on site at the facility. LPAs reviewed 1 of child's psychotropic medications and medication records. LPAs interviewed 3 of staff on site to discuss the facilities policies and procedures of operation. LPAs interviewed zero (0) children currently prescribed psychotropic medication. LPAs will conduct client interviews at a later date due to no clients being available during the time of inspection. No deficiencies are being cited at this time. A Technical Advisory was issued (see LIC 9102). LPA conducted exit interview and provided a copy of this licensing report to Jeanne Fletcher, Administrator.


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
During the interviews on Nov. 19th and 20th, all staff stated never witnessing a staff member hitting any client, but that the clients hit the staff. All staff were also able to verbalize the reporting requirements to CCL. LPA Palmer was also able to review nursing notes on 12/2/25 that identified C1 having a rash and that the rash was being monitored, but no other detail was present in the nursing notes. During an interview with C1, C1 also denies anyone hitting C1. All of the staff interviewed were also able to articulate the proper protocol regarding reporting requirements. All staff interviewed stated they report incidents immediately and within 24 hours via email and submit a written report within 7 days of the incident. LPA Moroney also conducted a complaint inspection regarding C1, where the allegations were: 1. Staff hit a minor in care, resulting in bruising and 2. The staff used inappropriate forms of discipline. After LPA Moroney reviewed records, including the clients' needs and services plans, medical records, SIRs and interviews with staff. Further, C1 also denied the allegations. Therefore, based on the information received, the above allegation(s) are determined to be unsubstantiated. Although the allegation(s) may have happened are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred; therefore, the allegations are found to be unsubstantiated. There are no deficiencies to be cited at this time. An exit interview was conducted and a copy of the report along with the (LIC 811) was left with the STRTP Facility Manager Page 2 of 2

Investigation Findings:
An amended report was sent to the Supervising Facility Manager, Cory Jackson for review and signature on 12/4/25. On November 7, 2025, at 8am , Licensing Program Analyst (LPA) Carrie Palmer conducted a complaint inspection at the above Short-Term Residential Therapeutic Program (STRTP) and met with Cory Jackson, Supervising Facility Manager to deliver the findings for the above listed complaint allegations. On November 6, 2025, LPA Palmer interviewed 4 staff members. (S1, S2, S3, S4), whom denied staff hitting any child with a shoe. When interviewing C1, C1 states liking living in the facility. Staff also stated that C1 has assaultive behavior towards staff daily and are trained to use ProAct to foster a safe environment for the staff and the clients. On Nov. 19, LPA Palmer conducted interviews with S5, S6, S7 and on Nov. 20, 2025 with S8. Page 1 of 2 .....Continued UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Carrie Palmer LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELOVED ONES 3FACILITY NUMBER: VISIT DATE: 11/07/2025

met_with: Cory Jackson, Supervising Facilty Manager


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Gilbert Gutierrez and Pamela Silva on July 28, 2022. During the inspection, LPAs met Thandi Smith, Administrator who provided the tour of the facility inside and out. LPAs conducted a tour of the facility at 9: AM. All medications are centrally stored, locked and accessible only to employees responsible for stored medications. There is adequate staffing in the facility to provide care and supervision to the clients. At the time of the inspection, LPAs observed the hot water temperature was 146 degrees Fahrenheit. LPAs reviewed a total of two staff records at 9:45am and conducted the interviews at 10:30am. No client currently placed in the facility is taking psychotropic medication.. A deficiency citation is issued at the time of the inspection. An exit interview was conducted and copy of LIC 809, LIC 809D and LIC 811 were provided to Administrator, .Smith.


summary: Facility Evaluation

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Narrative:
On 09/14/23 at 10: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced case management inspection at the above facility and met with the Director, Thandi Smith. The purpose of the inspection is to follow up on a referral from the county received by the Department on 08/30/23. The referral was regarding client C1 having inappropriate photos on her cellphone and sending inappropriate photos to an unknown person online (refer to Confidential Names List LIC811 dated 09/14/23). Based on review of Unusual Incident Reports (UIRs), the incident was not reported to the Department. During a telephone interview with the facility's director, he stated that the facility called the incident in to the Child Abuse Hotline but was not reported to the Department via UIR. The facility was in violation of Title 22, Division 6, Chapter 1, Article Reporting Requirements 80061(b)(1)(E). A Type B deficiency citation is being issued during today's inspection, see LIC809D. An exit interview was conducted. A copy of this report along with appeal rights were provided to the facility representative.


summary: Facility Evaluation

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Narrative:
On 11/28/23 at 9: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced case management inspection at the above facility and met with Facility Manager, Corie Thomas (S1). The purpose of the inspection is to follow up on physical plant observations made by LPA Claudia Portillo during a visit to the facility on 10/13/23. Upon arrival at the facility, LPA Silva observed that one client (C1) and one staff (S2) were about to leave the facility to go to school. S2 is a direct care staff. No facility manager was available at the time of LPA's arrival at the facility. This is in violation of Interim Licensing Standards (ILS) Personnel Requirements 87097.65(g) : The licensee shall designate at least one facility manager to be present at the facility at all times when one or more children are present. At 9:45AM, LPA Silva conducted the inspection and observed the following: · 80076(a)(22) Food service: Tableware and tables, dishes, and utensils shall be provided in the quantity necessary to serve the clients. o Observation: Needs and Services Plan (NSP) for C1 states that all materials that can be used for self-harm should be removed, including utensils, to reduce client risk of self-harm behavior. A set of silverware/utensils is now available and is locked up for potential clients' use. · Health and Safety Code section 1531.1 (e ): The facility shall be subject to all fire and building codes, regulations, and standards applicable to residential care facilities for the elderly utilizing delayed egress devices, and shall receive approval by the county or city fire department, o Observation: A fire extinguisher was available at the time of inspection, but was hidden inside the staff office and not mounted. 87088(c)(1)(2) Fixtures, Furniture, Equipment, and Supplies: (1) An individual bed maintained in good repair; equipped with good springs and a clean mattress; and supplied with pillow(s) which are clean and in good repair and (2) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; and bath towels, hand towels and wash cloths. o Observation: Mattress was equipped with a base/frame at the time of inspection. Pillows and linens were also available at the time of inspection. · 87088(c)(4) Fixtures, Furniture, Equipment, and Supplies: Portable or permanent closets and drawer space in the child's bedroom to accommodate the child's clothing and personal belongings. o Observation: Bedroom 2 has 1 drawer and Bedroom 1 has 2 drawers at the time of inspection. Bedroom 1 needs one more drawer. · 87072.2 (3) Complaint Procedures. Such procedures shall be posted in a location in the facility, which is accessible to children, their authorized representatives. o Observation: The procedures and forms were made accessible to children and authorized representatives at the time of inspection. · 80087 (a) Buildings and Grounds (CCR) : The facility shall be clean, safe and sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. o Observations: Curtain rods were in working order. The refrigerator still has a broken door handle. There is a hole in the wall in bedroom (2). LPA Silva issued seven (7) Type B deficiency citations during today's inspection. Plan of corrections were discussed with the Facility Manager. An exit interview was conducted. A copy of this report along with appeal rights were provided to the facility representative.

met_with: Corie Thomas


facility_name: BELOVED ONES 4

raw_content:
Narrative:
The investigation revealed that Ref. #1 was not patient and if Ref. #1 did not get things that Ref. #1 wanted in the moment, the Ref. #1 indicated that they felt disrespected. The CSW indicated that they had no concerns with Ref. #1's care while Ref. #1 resided at the facility. The CSW indicated that weekly meetings were held regarding Ref. #1 and the CSW met with the client once per month. There was no preponderance of the evidence to substantiate the allegations. So, although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the allegations are unsubstantiated. There are no deficiencies to be cited regarding these allegations. A copy of this complaint was provided to the facility representative.

Investigation Findings:
13On February 16, 2024 at 12:45 p.m., Licensing Program Analyst (LPA), Karen McGee delivered the findings of a complaint investigation to the facility. The LPA met with Administrator, Kenny Herrera. On October 19, 2023, the Monterey Park Children's Residential Program (MPCRP), received a complaint with the above mentioned allegations. Confidential interviews were conducted that included, but were not limited to: the Administrator, one client (see Confidential Names, LIC Ref. #1 dated February 16, 2024) was interviewed by LPA Vaishali Singh-Sood at the new placement; one County Social Worker via telephone on February 15, 2024. A second client Ref. #2 declined an interview on February 16, 2024 at the facility. The LPA reviewed the Needs & Services Plan and Incident Reports. The investigation did not reveal evidence to corroborate the allegation. It revealed that another client that was alleged to have lived at the facility never resided at the Beloved Ones 4 facility. The investigation revealed that Ref. #1 did not want to reside at the facility and preferred a location closer to their parent. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Karen McGee LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELOVED ONES 4FACILITY NUMBER: VISIT DATE: 02/16/2024

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

met_with: Kenny Herrera


raw_content:
Narrative:
Investigation revealed the following: It was alleged staff hit minor. Staff denied the allegation. Staff stated that one child was having an issue with another child and that child was attempting to assault and destroy property. Staff stated that child was intercepted by staff, but that staff never hit or put hands on child. Staff stated that child expressed concerns that they were getting physically abused in the home or having their property stolen but staff accommodated child by encouraging child to utilize lock and having staff sit in front of child's room to ensure no one entered room without permission. Interview reviewed with children denied the allegation. Children stated they liked the facility and that they either wanted to return or stay at facility. Children expressed no concerns with any staff or people in the facility. Interview conducted with CSW stated they had no concerns with home or children being placed in the home. CSW stated that one child was having issues, but issues presented seemed to be personal and not issues with facility or facility staff. Documents reviewed identified facility and facility staff took all necessary steps to address an issue with a child who was expressing concern with residing in the facility. No documents, medical assessments or statements identified any staff hitting a child. Based on information gathered, although the allegation may have happened or is valid, the preponderance of evidence to prove the allegation 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 the facility representative. There were no deficiencies cited during this inspection.

Investigation Findings:
13On February 7, Licensing Program Analyst LPA Winston Moroney made an unannounced visit to the Beloved Ones 4 facility on behalf of LPA Dawn Mahecha to close the above investigation. LPA met with representative and discussed the following findings to investigation. Investigation consisted of the following: On 12/11/ LPA Mahecha met with and interviewed facility manager and Administrator (see confidential names, LIC811 dated 12/11/2024). LPA reviewed one (1) file and obtained the following documents: Current LIC500/ client roster, one staff Proact training certification, policy, and procedure on the use of restraints, one (1) child's current needs and service plan, medical assessment from November and incident reports from November 22 thru December 2, 2024. On 2/5/ LPA interviewed County social worker (CSW) and reviewed statements and interviews conducted with child and additional witnesses. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Winston Moroney LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELOVED ONES 4FACILITY NUMBER: VISIT DATE: 02/07/2025

met_with: Kenny Herrera - Administrator


raw_content:
Narrative:
During the confidential interviews it was reported by S1 and S2 that clients are treated with dignity and respect. Staff do use the ProAct method to restrain clients when needed, but no one has ever been hurt and staff do not have any personal belonging of any client. Further, that if personal items are held and anytime, it is only for the safety of the clients in care. During confidential interviews with the clients revealed that 2 out of 2 children felt like they were being treated with dignity and respect. 1 out of 2 clients felt staff handled clients a little aggressively during restraining, but also mentioned their arm was already hurting (which had nothing to do with the staff) before the restraint took place. Additionally, 2 out of 2 clients stated that staff only take belongings from clients if they are a danger to themselves or others. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are unsubstantiated. No deficiency cited

Investigation Findings:
13On April 11, 2025 att 1:30pm, Licensing Program Analyst (LPA), Carrie Palmer conducted a follow-up complaint inspection with the above named facility and spoke the administrator. The purpose of the visit is to deliver the findings for the above complaint allegation. During the course of the investigation, LPA Palmer reviewed facility records and conducted investigative interviews with a total of 2 staff on 3/7/25, 1 client on 3/7/25 and 1 client on 3/21/25. (See Form Confidential Names). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Carrie Palmer LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELOVED ONES 4FACILITY NUMBER: VISIT DATE: 04/11/2025

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

met_with: Kenny Herrara, Adminstrator


raw_content:
Narrative:
cont.# A review of the Administrator and Facility Managers (FM1), FM#2 (FM2), FM#3 (FM3), FM#4 (FM4) and FM#5 (FM5) (see Confidential Names form LIC811 dated 07/25/2025) training records were conducted, and copies were made. The information revealed that the staff at this STRTP take most of their training in an online database, while other training is taken in person. The topics of training include, but are not limited to, crisis intervention, emergency procedures, trauma-informed care, and regulatory compliance. At the time of the file review FM1 and FM2 did not have a current cardiopulmonary resuscitation and first aid certificate. LPA Flores, having considered the evidence provided during the investigation, deemed the allegation substantiated. A citation was issued on LIC809 dated 4/22/2025 for violation of Interim Licensing Standards (ILS), Version 5: Section 87065.1 (b)(8)(A): (8) Facility manager training is in addition to first aid and CPR training, and other training as required in Section 87095.65. (A) Completion of cardiopulmonary resuscitation (CPR) and first aid training shall be demonstrated by current and valid CPR and first aid cards issued by the American Red Cross, the American Heart Association, a training program approved by the State Emergency Medical Services Authority pursuant to Health and Safety Code Section 1797.191, or from an accredited college or university. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. No further inspection is needed. A copy of this report, appeal rights and LIC811 was provided to the facility representative. Exit interview conducted.

Investigation Findings:
13On July 25, 2025, at 11:55AM, Licensing Program Analyst (LPA) Humberto Flores, conducted a follow-up complaint inspection at Beloved Ones Short Term Therapeutic Program (STRTP) and met with Alexandria Huertas. The purpose of the inspection was to deliver the findings for the above complaint allegation. The initial information that generated this complaint investigation stated that staff have not completed the required trainings at the facility . Reporting Paraty (RP) states the training is to ensure staff are equipped to handle resident care, crisis intervention, emergency procedures, trauma-informed care, and regulatory compliance. RP states that despite multiple email notifications sent to staff, no action has been taken to complete the training from Relias. LPA Flores investigated the allegation and conducted interviews with the Administrator and staff. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Humberto Flores LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELOVED ONES 4FACILITY NUMBER: VISIT DATE: 07/25/2025

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

met_with: Facility Manager, Alexandria Huertas


raw_content:
Narrative:
The next allegation was regarding the phone being in disrepair. During confidential interviews, it was reported by staff and clients that there was one phone in disrepair, but there was another phone working to ensure staff are able to conduct business and children are able to use the phone when they need to. Confidential interviews also revealed that the washer/dryer was not working properly, but the agency implemented processes to ensure children's laundry was washed at another facility until the washer/dryers were repaired. It was reported by staff and clients that the washer/dryer are in good repair at this time. The last allegation was regarding files being kept in a secure place. After speaking with S1, S2, S3 and the complainant it was revealed that files are kept in the office, in which the office can be locked. Within the office, the files are kept in a cabinet that has a lock on it. It was also stated that the door of the office is never locked and that the lock on the cabinet door doesn't work. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited. A copy of this report was provided to Kenny Herrera, Administrator.

Investigation Findings:
13On July 29, 2025 at 1: PM, Licensing Program Analysts (LPAs) Pamela Silva and Juliet Robles conducted a follow-up complaint inspection with the above named facility on behalf of LPA Carrie Palmer and spoke to Administrator, Kenny Herrera. The purpose of the visit is to deliver the findings for the above complaint allegation. During the course of the investigation, LPA Palmer reviewed facility records and conducted investigative interviews with S1, S2 on 4/11/25 and S3, C1 and the complainant on 7/28/25. (see Confidential Names). During the confidential interviews regarding the allegation of the facility van being in disrepair. It was clarified that the vehicle was not a van, but it was a car, which the facility no longer uses. The car has been replaced with another vehicle which staff and clients state is working properly per S3, S2 and S1. Staff also provided LPA Palmer with invoices to show that the agency has processes in place to repair vehicles in the event that they breakdown. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Pamela Silva LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELOVED ONES 4FACILITY NUMBER: VISIT DATE: 07/29/2025

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