facility_name: LYON

raw_content:
Narrative:
statements saying, "I love you" and referring to each other as "babe." Confidential interviews reported the expression of love was given to multiple residents to demonstrate care, compassion and to build rapport with residents, and the term "babe" was common language within the facility. Confidential interviews could not confirm or dispute that the messages sent between S1 and C1 were of a romantic nature or there was an inappropriate relationship between S1 and C1. Based on record review and confidential interviews the allegation of Staff (S1) was engaging in an inappropriate relationship with minor (Child #1 [C1]), may or may not have occurred, however it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of the report was provided along with appeal rights to Lyon Short Term Residential Therapeutic Program (STRTP) Administrator (ADM) Courtney Brandon.

Investigation Findings:
13On February 10, 2023 at 12:10 pm Licensing Program Analyst (LPA), Nicole Strickland, met with Lyon Short Term Residential Therapeutic Program (STRTP) Administrator (ADM), Courtney Brandon, to deliver the finding for the above stated allegation. LPA conducted an inspection of the facility on March 16, 2022 at approximately 1:30 pm and no immediate deficiencies were observed. The investigation was conducted LPA Strickland and included interviews with ADM, Staff #1 (S1). Three confidential witness did not respond to LPA's request for an interview or current whereabouts were unknown and therefore were not interviewed. In addition, county records and facility records were reviewed. On March 10, Community Care Licensing (CCL) received an allegation alleging Staff (S1) was engaging in an inappropriate relationship with minor (Child #1 [C1]). Specifically it was reported during computer checks at the facility messages between S1 and Child #1 (C1) were found indicating a romantic relationship between the two. Confidential interviews and record review revealed messages between the two included UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Nicole Strickland 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 19-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, MAIN ST., SUITE FACILITY NAME: LYONFACILITY NUMBER: VISIT DATE: 02/10/2023

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

met_with: Courtney Brandon


state: CA

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
and encourage them to stay. If clients AWOL staff will contact the appropriate parties to report the AWOL. Further details stated that there are some clients that chronically AWOL from the facility. Other details gathered from confidential interviews state that staff does not prevent clients from AWOL and does not do much to prevent clients from leaving the facility. Regarding the allegation that staff yells at minor and staff does not treat minor with dignity and respect, confidential interviews disclosed that staff yells at minors. Other interviews provided information that staff will use a stern tone of voice in order to re-direct and de-escalate minors when clients become aggressive towards staff or other peers in the home. Further details gathered from confidential interviews, state that clients and staff will joke with one another and that sometimes staff or clients will go too far and clients' feelings will get hurt. Further information gathered, denied that staff yells at minors and that every client is treated with respect and did not witness or hear staff yelling at minors in care or not treating minors with dignity and respect. Regarding the allegation that staff confiscated minor's privilege of phone and television usage, confidential interviews disclosed that staff denies clients phone and television usage. Other confidential interviews stated that staff will take away privileges but that clients get the privileges back. Further details gathered disclosed that some clients misused their usage and therefore had privileges taken away but were later given them back. Based on record review and confidential interviews the allegations alleging that minor went AWOL from facility, staff yells at minor, staff does not treat minor with dignity and respect, and staff confiscated minor's privilege of phone and television usage, may or may not have occurred. However, it is not supported or proven by the evidence. Confidential interviews could not confirm or dispute these allegations; Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted, appeal rights were discussed and provided. A copy of this report was given to Administrator, Linda Poythress.

Investigation Findings:
13On June 21, 2023 at 11:02 am Licensing Program Analyst (LPA), Emina Preciado, met with Lyon STRTP Administrator (ADM), Linda Poythress, to deliver the findings for the above stated allegations. LPA Lisi Leon conducted an inspection of the facility on June 21, 2022 at approximately 12:15 pm and no immediate deficiencies were observed. The investigation included interviews with two staff, one facility manager (FM, S1, and S2) and three out of six foster youth (C1, C5, C6). Two confidential witnesses did not respond to LPA's request for an interview and one confidential witness whereabouts are unknown and were, therefore, were not interviewed. In addition, county records and facility records were reviewed. On June 15, 2022, Community Care Licensing (CCL) received four allegations alleging that minor went AWOL from facility, staff yells at minor, staff does not treat minor with dignity and respect, and staff confiscated minor's privilege of phone and television usage. Regarding the allegation that minor went AWOL from the facility, confidential interviews disclosed that staff encourages clients to not AWOL by using re-direction so that clients do not leave *next page...* UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Emina Preciado 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 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: LYONFACILITY NUMBER: VISIT DATE: 06/21/2023

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

report_type: Complaint Investigation

met_with: Linda Poythress

complaint_status: unsubstantiated


raw_content:
Narrative:
Confidential interviews reported that staff created a plan for C1 not to have phone privileges due to behavior issues and house rules, and C1's authorized representative agreed to the plan. Confidential interviews reported that C1 was using the phone for extended periods and using the phone outside of the house rules time. Confidential interviews reported that C1 would take the facility's house phone, hide it in their room, and keep it for personal use. Confidential interviews revealed staff created boundaries for C1's phone use due to C1's history of talking with unknown people and becoming physically upset whenever C1 would finish the phone call. Confidential interviews and documentation revealed that after C1 talked with unknown people, staff feared that C1 would become physical in interacting with staff. Confidential interviews revealed when C1 was on hold of the facility house phone, and if C2 and C3 requested to use the phone, staff would allow them to use the staff phone for their calls. Based on inconsistence confidential interviews, the allegations that staff are not allowing youths in care (C1, C2 & C3) to use the telephone is unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted, and a copy of this report LIC 9099 and the appeal rights were discussed and provided to Stacey Rougely, Administrator.

Investigation Findings:
13On April 4, 2024, Licensing Program Analyst's (LPA's) Cynthia Robinson and Leslie Covarrubias met with Stacey Rougely, Administrator to deliver the compliant findings to the allegation listed above. LPA Robinson conducted a health and safety inspection on 02/09/2024 at 9: AM, and no immediate health and safety concerns were observed. During the investigation, LPA Robinson conducted confidential interviews with Staff 1(S1), Staff 2 (S2), Staff 3 (S3), Staff 4 (S4), and Clients (C1, C2 & C3). LPA obtained copies of related Special Incident Reports (SIRs), the client roster and staff roster, and the placement agreements for C1, C2, and C3. LPA obtained other pertinent documents needed for the investigation. On 02/29/2024, Community Care Licensing (CCL) received a complaint that facility staff are not allowing youths (C1, C2, & C3) in care to use the telephone. It was reported to CCL that C1 was not allowed to use the phone for a week, and the client's phone was missing for a week, thus not allowing C1, C2 & C3 to use the phone. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Cynthia Robinson 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 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: LYONFACILITY NUMBER: VISIT DATE: 04/04/2024

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

met_with: Stacey Rougely, Administrator


raw_content:
Narrative:
During the investigation, there was no corroborating evidence to support the above allegation. Although the Department received information that S1 pushed C3 out of the way to unplug the television. Confidential interviews revealed that S1 did not touch C3 but reached around C3 to unplug the television. Confidential interviews revealed that C3 asked C1 and C5 to be witnesses to say S1 had pushed C3, however, C1 and C5 retracted their statements and stated they never saw S1 push C3 out of the way. Based on inconsistent confidential interviews, the allegations that S1 handled minor in care in a rough manner may have occurred, however, is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with appeal rights was provided to Lyon Short Term Residential Therapeutic Program (STRTP), Youth Partner, Randy Davis.

Investigation Findings:
13On 05/15/24 at 09: AM, Licensing Program Analyst (LPA) Sarah Lo met with Youth Partner, Randy Davis, to deliver the finding for the above complaint allegation at Lyon Short Term Residential Therapeutic Program (STRTP). On 12/19/23, LPA Emina Preciado inspected the facility's physical plant, and no immediate health and safety hazards were observed. The investigation included interviews with two staff members (S1 and S2), Residential Manager (RM), Probation Officer (PO) and five clients (C1, C2, C3, C4 and C5). Clients' Needs and Services Plans and case notes were reviewed. On December 15, 2023, Community Care Licensing received an allegation that staff (S1) handled minor in care in a rough manner. Specifically, it was reported that S1 had used the hands to push C3 out of the way to unplug the television and S1 used their body to shove C3 away from the television to keep from C1 plugging in the television cord. (Continued on LIC 9099c) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Sarah Lo LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: LYONFACILITY NUMBER: VISIT DATE: 05/15/2024

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

met_with: Youth Partner, Randy Davis


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Other confidential interviews stated that they did not hear S1 say inappropriate statements to C1. In addition, confidential interviews disclosed that S1 did not close the door on C1's hand, but C1 slammed the mini-refrigerator door shut themselves (C1). Regarding the allegation that staff (S1) threatened a minor (C1) in care, confidential interviews disclosed that S1 threatened "to call their people" on C1 and threatened C1 with a firearm. Confidential interviews indicated that S1 did not use threatening words toward C1 or a firearm. Per the facility, no firearms are kept at the facility. LPA could not determine if S1 threatened C1 or not. Based on inconsistent confidential interviews, the allegation that staff slammed a door on a minor's hand and staff threatened a minor in care may have occurred, however is not supported, or proven by evidence. Therefore, the above allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report LIC 9099 and the appeal rights were discussed and provided to Stacy Rougely, Administrator.

Investigation Findings:
13On December 17, 2024, Licensing Program Analyst (LPA) Cynthia Robinson met with Stacy Rougely, Administrator to deliver the complaint findings to the above allegations. LPA Robinson inspected the STRTP on 09/13/2024 and observed no health and safety concerns. LPA Robinson obtained documents pertinent to the investigation. During the investigation, LPA Robinson conducted confidential interviews with Staff 1 (S1), Staff 2 (S2), Staff 3 (S3), Client 1 (C1), Client 2 (C2), and Client 3 (C3). LPA attempted to interview Client 3 (C3) and Client 4 (C4); however, C3 and C4 declined to be interviewed. On 09/09/2024, Community Care Licensing (CCL) received a complaint that staff (S1) slammed a door on a minor's (C1) hand, and staff (S1) threatened a minor (C1) in care. Specifically, it was alleged that S1 slammed C1's hand with a mini-refrigerator door. Confidential interviews disclosed that C1 attempted to reach the mini-refrigerator to grab a Gatorade drink, and S1 slammed the door on C1's hand. Additional confidential interviews disclosed that C2 heard the refrigerator close, and S1 allegedly told C1, "Your hand shouldn't have been there". (Continued on LIC 9099C...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Cynthia Robinson 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 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: LYONFACILITY NUMBER: VISIT DATE: 12/17/2024

met_with: Stacy Rougely, Administrator


raw_content:
Narrative:
Documentation reported that the facility notified the authorized representatives the day the clients were evacuated to the hotels on 01/10/2025. LPA was unable to determine the timeframe of when the minors' authorized representatives were or weren't contacted. Based on inconsistent confidential interviews and documentation, the allegation that staff did not properly report an incident involving the minors is unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of evidence to prove that the alleged violations occurred. LPA issued a Technical Violation LIC9102, to remind the facility to follow the reporting requirements in the STRTP Interim Licensing Standards. An exit interview was conducted, and a copy of this report LIC 9099 and the appeal rights were discussed and provided to Stacy Rougely, Administrator.

Investigation Findings:
13On March 24, 2025, 2024 at 12: AM, Licensing Program Analyst (LPA) Cynthia Robinson conducted an unannounced visit to Olive Crest Lyon Short-Term Residential Therapeutic Program (STRTP) to deliver the investigative findings for the above allegation. On 01/17/2025, LPA Robinson conducted a health and safety inspection at the STRTP and obtained documents pertinent to the investigation. LPA interviewed clients (C1, C2, and C3), staff (S1 and S2), County Social Workers (CSW1 and CSW2), and Probation Officer (PO). On 01/15/2025, Community Care Licensing received an allegation that staff did not properly report an incident involving the minors. It was alleged that during a facility evacuation due to power outages, the clients were placed in a hotel for the weekend from 01/10/2025 to 01/13/2025 and authorized representatives of the clients (C1, C2, C3, C4, and C5) were not notified. Confidential interviews reported that the facility did not contact authorized representatives until clients were placed back in the facility but was unsure on which day authorized representatives were notified. (Continued on LIC 9099C...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Cynthia Robinson 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 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: LYONFACILITY NUMBER: VISIT DATE: 03/24/2025

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


summary: Facility Evaluation

raw_content:
Narrative:
***This is an Amended Report of the report issued on 10/05/21. On October 5, 2021, at 11: AM Licensing Program Analyst (LPA) Leslie Covarrubias and Licensing Program Manager (LPM) Jennifer Smith arrived at Lyon, Short Term Residential Program (STRTP). LPA and LPM met with Residential Manager, Tyresha Calhoun. The purpose of the visit is to conduct an annual inspection of the facility. At 11: AM, Residential Manager, Tyresha Calhoun, led the physical inspection of the facility. The home is set up as follows: Bedroom #1- Was furnished with one twin bed. Sleeps one client. Bedroom #2- Was furnished with one twin bed. Sleeps one client. Bedroom #3- Was furnished with one twin bed. No client is placed in this room at this time. Bedroom #4- Was furnished with one twin bed. Sleeps one client. Bedroom #5- Was furnished with one twin bed. Sleeps one client. Bedroom #6- Was furnished with one twin bed. Sleeps one client. Bedrooms are arranged so that only one child is placed per room. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There is adequate drawer and closet space for children's belongings. The dresser drawer in room #2 was observed to be cracked approximately in the middle of drawer and on the verge of breaking off. A physical plant inspection was completed and included the facility's kitchen area, three refrigerators/freezers, food storage areas, client rooms, two bathroom/showers, and community gathering area and dining area. Facility grounds are clean and free of debris and observable hazards. Sports equipment/toys/books/games were observed for client's recreation time. There is adequate indoor and outdoor activity space. Facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and the menus were posted. At the time of inspection the facility license was observed to be posted in the staff office, which is not a public area of the facility. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsperson poster. Medications are locked and centrally stored inside staff office. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client's bathrooms was measured to be an appropriate temperature. Per the Residential Manager, no firearms or weapons are allowed in the facility. LPA and LPM inspected the facility vehicle, and observed that the second row seat belt buckles are missing the outside covers. The facility was advised not to allow use of the second row until repair of the seat belt buckles is completed. LPA and LPM also inspected the First Aid Kit and found it was missing tweezers and scissors. Licensee has Mental Health Program Approval that is valid through 12/2021. Licensee has obtained National Accreditation that is valid through 10/2021. Licensing fee payments have been paid and there is currently a balance of $0. No deficiencies were cited at this time. An exit interview was conducted and a copy of this report, LIC9102 and appeal rights were provided to Residential Manager, Tyresha Calhoun.

report_type: Facility Evaluation

visit_type: Annual

met_with: Residential Manager, Tyresha Calhoun


summary: Facility Evaluation

raw_content:
Narrative:
On November 10, 2021, at 8:35am, Licensing Program Analyst (LPAs) Ronnesha Fountain and Leslie Corvurriabias conducted an announced inspection. The purpose of the inspection was to complete the continuation inspection for STRTP annual inspection that was initiated on October 05, 2021. LPA's already completed the physical inspection, staff records, and staff interviews of the facility. During this annual inspection continuation LPAs interviewed four of the six clients to ensure the STRTP are meeting the Title Regulations and Interim Licensing Standards (ILS), see LIC 811 dated 11/10/21. The client interviews are located under the LIC 809 dated 10/22/21. Based on interview with clients, there was some confusion over the "point system" used that determines the amount of cash a client can keep on them physically, but the amount that is deposited into their savings does not change. In-addition, there was some concern over the food menu; however, it was noted that staff allows for the clients to give suggestions and they will do their best to accommodate them. The STRTP appears to be meeting Core Services/Supports requirements. Due to only the physical plant, and client interviews being completed this inspection will be continued at a later date. No deficiencies were found during this inspection. An exit interview was conducted and a copy of this report was provided to the residential manager Anne Lacy.

visit_type: Case Management

met_with: Anne Lacy


summary: Facility Evaluation

raw_content:
Narrative:
On November 30, 2021, Licensing Program Analyst's (LPA's) Leslie Covarrubias, Lisi Leon, and Licensing Program Manager (LPM), Jennifer Smith arrived at Lyon STRTP for the purpose of issuing an amended report of the Annual Inspection conducted on October 5, 2021.

met_with: Residential Manager, Randal Brown


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
***This is an amended report of the original report on 11/30/2021.*** On November 30, 2021, at 9: AM, Licensing Program Analyst's (LPAs) Leslie Covarrubias, Lisi Leon, and Licensing Program Manager (LPM) Jennifer Smith arrived at Olive Crest - Lyon Short-Term Residential Therapeutic Program (STRTP). The purpose of the inspection was to complete the continuation inspection for STRTP annual inspection that was initiated on October 5, 2021. LPAs and LPM already completed the physical inspection of the facility on the first day of the annual inspection. During this annual inspection continuation, the LPAs and LPM reviewed 5 of 5 client files (see LIC 811, dated 11/30/21). Client files are kept in a locked cabinet in the staff office. Client #2 (C2) did not have medical insurance information, such as medical card, therefore the facility is being cited for ILS 87070(b)(9) Children's Records. C2 and Client #3 (C3) did not have a TB test on file, therefore, the facility is being cited for CCR 80069(c)(1) Client Medical Assessments. All clients (C1-C5) did not have the ambulatory status defined by a licensed physician, therefore the facility is being cited for CCR 80069(c)(4) Client Medical Assessments. Client #1 (C1) and C3 did not have staff initials on the medication log to indicate that they supervised the medication being administered, therefore the facility is being cited for ILS 87070(b)(12)(H) Children's Records. LPAs and LPM reviewed and 7 of the 7 personnel files to ensure they contained all required documentation per Title Regulations and Interim Licensing Standards (ILS). All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Personnel Files are usually maintained at the corporate office in Riverside. Staff #2 (S2), #3 (S3), and #5 (S5) were missing documentation of required training, therefore the facility is being cited for ILS 87066(b)(4) Personnel Records. S2, S3, and S5 were missing required training, therefore the facility is being cited for ILS 87065.1(c) Training Requirements. S S3 and S5 were missing required training, therefore the facility is being cited for ILS 87065. Training Requirements. [...] Due to time constraints the annual inspection will be completed at a later date. An exit interview was conducted and a copy of this report along with LIC 809D, LIC 811 and Appeal Rights were given to Residential Manager, Randall Brown.

Deficiencies:
87065.1(c): Training Requirements

(c) Notwithstanding California Code of Regulations, Title 22, Section 80065(f)(1) through (6), new direct care staff shall complete a minimum of 24 hours of initial training comprised of the 8 and 16 hour training as specified in (1) and (2) below
87065(f): Personnel Requirements

(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

met_with: Residential Manager, Randall Brown


summary: Facility Evaluation

raw_content:
Narrative:
On February 17, 2022, at 10: AM, Licensing Program Analyst's (LPAs) Leslie Covarrubias and Lisi Leon arrived at Olive Crest - Lyon Short-Term Residential Therapeutic Program (STRTP). The purpose of the inspection was to complete the continuation inspection for STRTP annual inspection that was initiated on October 5, 2021. LPAs previously completed the physical inspection, reviewed staff and client files, conducted client interviews of the facility on the prior days of the annual inspection. During this annual inspection continuation, the LPAs reviewed the Administrator File, completed the Operational Requirements, Disaster Preparedness, Emergency Intervention Plan, Core/Therapeutic Services, and Clients with Special Health Care Needs. LPAs conducted staff interviews with the two staff present at the time of inspection. All staff were able to provide sufficient information in relation to the facility's STRTP program. Staff have no issues or concerns regarding the facility. Based upon the inspection of facility records and interviews with staff, the Licensee appears to be meeting CFT and Core Services/Supports requirements. No deficiencies were found during the time of inspection. LPAs requested a copy of the updated Accreditation Approval Letter as the expiration date was on 10/30/2021. At the time of inspection the Approval Letter was emailed by the Administrator to LPA Leslie Covarrubias. LPAs also inquired about the Mental Health Approval status as the expiration date was on 12/31/2021. Administrator stated the Mental Health Approval is in process and would email the copy to LPA Covarrubias once completed. An exit interview along with a copy of this report (LIC 809) and Appeal Rights were discussed and provided to Administrator, Ricardo Calzada.

met_with: Residential Manager, Ricardo Calzada


summary: Facility Evaluation

raw_content:
Narrative:
On March 29, Licensing Program Analyst (LPA) Leslie Covarrubias met with Facility Administrator, Ricardo Calzada for the purpose of issuing an amended report. A copy of this was discussed and provided to Facility Administrator, Ricardo Calzada..

met_with: Facility Administrator, Ricardo Calzada


summary: Facility Evaluation

raw_content:
Narrative:
On October 20, 2022, Licensing Program Analyst (LPA), Lisi Leon made an unannounced case management inspection for the purpose of reviewing an incident that occurred on or around October 2, 2022 with Client #1 (C1)(see Confidential Names form LIC 811, dated 10/20/2022). LPA Leon met with Facility Manager, Courtney Brandon, regarding the incident. LPA received a complaint regarding OliveCrest - Beazer (336403863) regarding a youth AWOL'ing to OliveCrest - Lyon resulting in the youth spending the night in the home and taking a shower with C1. Interview was conducted with the Facility Manager and LPA gathered records for C1 and employee (S1, S2) to assist with the case management. An exit interview was conducted and a copy of this report was provided to facility representative.

met_with: Facility Manager, Courtney Brandon


summary: Facility Evaluation

raw_content:
Narrative:
On October 26, 2022, at 01: PM Licensing Program Analyst(s) Lisi Leon and Eduardo Barragan arrived at the facility to issue an immediate exclusion order for staff (S1) for an incident unrelated to this facility. LPA advised the facility to adhere immediately to the exclusion order. Copies of the exclusion order was provided to Lead Residential Manager for Olive Crest Facilities: Lyon Facility# 336403698, Beazer Facility#336403863, Forecast Facility#336403949 and Richmond Facility#336403699 due to S1 being associated to all four facilities. A copy of the exclusion order was also provided to S1. An exit interview was conducted. A copy of the report and the appeal rights with the exclusion order was provided to Tyresha Calhoun and Ricardo Calzada.

met_with: Lead Residential Manager, Tyresha Calhoun


summary: Facility Evaluation

raw_content:
Narrative:
On February 8, 2023 at 10: AM, Licensing Program Analyst (LPA) Gloria Meza-Gonzalez conducted an unannounced inspection at the above facility. LPA Meza-Gonzalez met with Program Administrator (PA) Courtney Brandon. The purpose of the inspection is to conducted a confidential client (see confidential name list, LIC811, dated: February 8, 2023) interview regarding a previous placement. Exit interview was conducted and a copy of this report was left with PA Brandon.


summary: Facility Evaluation

raw_content:
Narrative:
On November 17, 2023 at 12:11 pm, Licensing Program Analyst (LPA), Emina Preciado, arrived at Lyon, Short Term Residential Therapeutic Program (STRTP) for the purpose of conducting a required annual inspection. LPA met with Residential Manager, Linda Poythress. The purpose of the visit was to conduct an annual inspection of the facility. While at the facility, LPA reviewed client and facility records, conducted two staff interviews and two client interviews. LPA conducted a physical plant inspection at 12: PM, Residential Manager, Linda Poythress, led the physical inspection of the facility. The home is set up as follows: A physical plant inspection was completed and included the facility's kitchen area, three refrigerators/freezers, food storage areas, client rooms, two bathroom/showers, a community gathering area, and dining area. Facility grounds are clean and free of debris and observable hazards. Washers and dryers are in working order. Sports equipment/toys/books/games were observed for client's recreational time. There is adequate indoor and outdoor activity space. Facility smoke detectors and carbon monoxide detectors are in appropriate working order; Licensee maintains an adequate supply of perishable and non-perishable foods and the menus were posted. Licensee has Mental Health Program Approval that is valid through 12/10/2023. All required forms are posted including the Facility License, Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsperson poster. Medications and cleaning supplies are locked and centrally stored inside staff office. Per the Residential Manager, no firearms or weapons are allowed in the facility. Bedroom #1- Furnished with one twin bed, sleeps one client, and is occupied. Bedroom #2- Furnished with * LIC 809-C* one twin bed, sleeps one client, and is occupied. Bedrooms #3, 4, and 6- Furnished with one twin bed and sleeps one client. No clients are placed in the rooms at this time. Bedroom #5- Was Furnished with one twin bed, sleeps one client, and is occupied. The bedrooms are arranged so that only one child is placed per room. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. During the inspection, LPA reviewed three of three client records. LPA observed that Client #1 did not have a medical or dental assessment on file within 30 days of placement, please refer to the LIC 811 (confidential names list) dated November 17, 2023. The licensee was given a Technical Violation and advised that clients must have a medical assessment within 30 days of placement. Due to time constraints, LPA will be returning at a later date to complete the inspection. Exit interview conducted, appeal rights were discussed and provided; A copy of this report along with LIC 809-C, LIC 811, and 9102 were provided Residential Manager, Linda Poythress.

met_with: Linda Poythress, Residential Manager


summary: Facility Evaluation

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On November 21, 2023 at 9:33 am Licensing Program Analyst (LPA), Emina Preciado, conducted an unannounced visit at Olive Crest- Lyon, Short Term Residential Therapeutic Program (STRTP). LPA met with Residential Manager, Linda Poythress. The purpose of the visit was to continue a required annual inspection that was initiated on November 17, 2023. LPA completed the Physical Plant, Client Records, Operational Requirements, and Staff/Client Interviews portion of the inspection on November 17, 2023. While at the facility, LPA completed the Staffing Records, Emergency Intervention Plan, Disaster Preparedness, and Core Therapeutic Services portion of the inspection. LPA met with Human Resources Administrative Manager to conduct the Staff Records review portion of the inspection on November 13, 2023 at Olive Crest (336425183) located at: Technology Court Suite Riverside, CA 92507. LPA reviewed five personnel records, to ensure they contained required documentation per Title Regulations and Interim Licensing Standards (ILS). Five out of five personnel records reviewed were associated to the facility and had completed background clearances: Department of Justice (DOJ), Federal Bureau of Investigation (FBI), and Child Abuse Central Index (CACI) on file. Five out of five personnel records reviewed had a health screening and tuberculosis (TB) test on file. Five out of five personnel records reviewed had annual training's, current cardiopulmonary resuscitation (CPR), and first certification on file. Based on staff/client interviews, the facility appears to be meeting Core Therapeutic Services, and Supports, and Emergency Intervention Plan requirements. Based on observation and record review, there are no deficiencies noted at this time during the inspection. Exit interview conducted, appeal rights were discussed and provided; And a copy of this report was provided to Residential Manager, Linda Poythress.


summary: Facility Evaluation

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An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPA) Joon Choi and Claudia Aguilera on May 15, 2025 at 09: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs Choi Aguilera met with Administrator Stacy Rougely and conducted a health and safety inspection of the facility and no immediate deficiencies were observed. LPAs reviewed one of child's records and two of staff personnel files on site at the facility. LPAs reviewed one of child's psychotropic medications and medication records. LPAs interviewed two of staff on site to discuss the facilities policies and procedures of operation. LPAs interviewed one child that is currently prescribed psychotropic medications. No deficiencies are being cited at this time. LPA conducted exit interview with Administrator Stacy Rougely and provided a copy this LIC 809 report.

met_with: Stacey Rougley, Administrator


summary: Facility Evaluation

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On December 1, 2025, at 10:20 am Licensing Program Analyst (LPA) Julian Lucas arrived at Lyon Short Term Residential Therapeutic Program (STRTP). The purpose of this visit was to conduct an unannounced annual random inspection. LPA was met at the facility by the Administrator Stacy Rougely. The walkthrough included the interior and exterior of the facility. The facility grounds are clean and free of debris. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, the Emergency Disaster Plan was also posted. LPA was able to review three staff files that was associated with the facility. Due to the facility undergoing renovations. LPA will return at a later date to complete the physical plant inspection, and review client records.

met_with: Stacy Rougely


summary: Facility Evaluation

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Narrative:
On October 2nd, 2023, at 9:53 am Licensing Program Analyst (LPA), Emina Preciado, met with Lynda Poythress, Facility Administrator, to deliver a case management deficiencies report. During an unannounced visit to the facility on 9/27/23, LPA conducted a health and safety inspection. During the inspection, LPA observed that the facility was not in good repair. LPA observed that the carpet in the living room of the facility had a ten-to-eleven-inch tear, the fibers of the carpet were exposed and lifting. In the hallway of the facility, going toward the client bedrooms, LPA observed that the carpet was lifting and had fibers exposed. LPA observed that the window blind in Bedroom # 4 was not in good repair. The window blind was missing pieces and coming undone. Facility Administrator informed LPA that there was a work order in place to replace the window blind. Based on observation and evidence gathered the facility is cited for Tittle 22, Division Chapter 1, Article 07. Buildings and Grounds 80087(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. Which poses a potential health and safety risk to clients in care. Exit interview conducted, appeal rights discussed and provided; And a copy of the following reports: LIC809 and LIC809-D were given to Lynda Poythress, Facility Administrator.

met_with: Lynda Poythress, Administrator


summary: Facility Evaluation

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Narrative:
On December 19, Licensing Program Analyst (LPA), Emina Preciado, conducted an unannounced visit at the facility for the purpose of an independent investigation. While at the facility, LPA conducted a health and safety inspection. During the inspection, LPA observed the following: the facility did not have an adequate supply of non-perishable food to meet client ratio, bathroom #2 had exposed electrical wires from an uncovered light switch, there were holes in the facility walls (living room & hallway), and a hole on the door of bedroom #4. Based on observation, interviews, and evidence gathered, the facility is cited for California Code of Regulations (CCR), Buildings and Grounds 80087(a), "The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors." and Interim Licensing Standards (ILS), Food Service, 87076(c)(1) "Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises." which poses an immediate health and safety risk to clients in care. Additionally, LPA advised Residential Manager, Linda Poythress about a distinct odor that LPA observed in a cabinet, under the facility's kitchen sink. Exit interview conducted, appeal rights were discussed and provided; And a copy of the following reports: LIC809 and LIC809-D were given to Lynda Poythress, Residential Manager.


facility_name: MAKADE BEHAVIORAL CENTER #1

summary: Facility Evaluation

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On September 17, 2025, Licensing Program Analysts (LPA) Jessica Peete and Cynthia Urena met with Makade Behavioral Center applicant Jorge Cervantes to complete Component II, the face-to-face interview, for the Short Term Therapeutic Residential Program (STRTP) application process. Also present were Board Secretary Imelda Cervantes and Chief Operations Officer Akila Crane, who attended via Microsoft Teams, and the prospective Administrator Laura Hartney. The applicant previously attended Component I, the STRTP orientation, on February 25, 2025. The purpose of today's meeting was to address any questions or concerns and to review the application packet and process, ensuring that the applicant, designated administrator, and all relevant parties understand and can provide the services outlined in the Program Statement and Plan of Operations in compliance with Community Care Licensing regulations. LPA reviewed the application documents, addressing and correcting discrepancies on the LIC Application for Community Care Facility and LIC Applicant Information. Policies and procedures submitted as part of the application, including discipline policies, program description, population to be served, and personal rights, were also reviewed. The facility staff plan was discussed to ensure compliance. The applicant does not yet have direct care staff but stated that a temporary staffing plan is in place. LPA reminded the applicant of the required staff-to-client ratios and reviewed the relevant regulations outlined in STRTP Interim Licensing Standards (ILS) 87065.5. Additionally, LPA reviewed the qualifications and educational requirements for the Administrator, Social Worker, and Facility Manager. As the applicant is required to have three months of operating expenses, LPA reviewed the necessary financial LIC forms to ensure sufficient resources to operate the STRTP. LPA also discussed the required financial documentation, including the LIC Monthly Operating Statement and the supportive financial verifications. LPA informed the applicant and attendees of the next steps in the application process and requested the following documentation to be provided by or before the scheduled technical assistance meeting: Updated LIC Monthly Operating Budget LIC Personnel Report Administrator qualifications for prospective Administrator Laura Hartney Verification of social worker educational requirements LIC Designation of Facility responsibility with either the board meeting minutes or a resolution confirming the authorized designee is permitted to sign. An exit interview was conducted and a copy of this report was provided to the applicant

met_with: Jorge Cervantes,Imelda Cervantes,Akila Crane, Laura Hartney


summary: Facility Evaluation

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On January 13, 2026, at 11: AM Licensing Program Analyst (LPA) Jessica Peete met via Microsoft Teams with Makade Behavioral Center Short Term Residential Therapeutic Program (STRTP) Chief Operating Officer (CEO) Jorge Cervantes and Director Akila Crane to discuss and review the STRTP's second Revised Plan of Operations and Program Statement, submitted to Community Care Licensing by email on December 30, 2025. The meeting covered the Plan of Operation and Program Statement, focusing on the staff training plan for Peer Partners and Volunteers, as well as annual and Facility Manager Training. LPA also discussed Social Worker qualifications, Administrator qualifications, and the facility sketch. LPA advised the applicant that the facility sketch on file must include the dimensions of all areas used by the population served, as required by Interim Licensing Standards (ILS) 87022(5)(A). LPA also reviewed best practices, areas for improvement, and regulatory alignment. The facility currently has a qualified Administrator with an approved exception to be on the premises for at least 20 hours per week at each Makade location in Riverside and Corona to manage and administer the STRTP in compliance with ILS regulation 87064(b)(1). The CEO and Director were also told that corrections or revisions should be highlighted for easy reference during the review. The second revised Plan of Operation and Program Statement will be due January 15, 2026. The following is a summary of the review of the Plan of Operations and Program Statement completed by LPA Jessica Peete: (Continued on LIC C) Application and Supporting Documentation (LIC 281E) Social Worker Qualifications ILS 87065(c)- Standard Not Met · Provide Transcripts from an accredited school · Social work staff hired on or after January 1, 2017, shall meet the following education and experience requirements: · A master's degree from an accredited or state approved graduate school, as defined by the Department of Education, in social work or social welfare, marriage, family and child counseling, child psychology, child development, counseling psychology or social psychology · Completion of at least three (3) semester units or 100 days of field practice or experience in a public or private social service agency at the master's degree level. · At least nine (9) semester units of coursework related to children and families, or 18 months' experience in working with children and families. · At least three semester units in working with minority populations, or six months of experience in working with minority population; or six months in-service training in working with minority populations within the first year of employment as a condition of employment. · At least three semester units in child welfare, or two years' experience in a public or private child welfare social services setting. Administrator Qualifications ILS87064(c) -Standard Not Met · Makade Behavioral Center 1 #337900294-Verify current Administrator Certificate Plan of Operations A. Purpose and Goals-Standard Met · Will serve female/male youth ages 10-17 and non-minor dependents (NMD) up to the age of 21 (Continued on LIC C) B. Administrative Organization -Standard not Met · Page Update Job Duties and Responsibilities to include all the administrative duties as listed in ILS 87064(d)(1)-(10) · Page 49 update Social Worker required qualifications to align with the accepted degrees, work experience, and requirements as outlined in ILS 87065(c)(1)(A)-(F) and 87065(c)(2) · See Best Practice Notes C. Facility Sketch STRTP ILS Sections 87022, 87087, 87087.1, 87087.2-Standard not Met · The sketch should be updated to include the dimensions of all areas which will be used by the population(s) served. ILS 87022(5)(a). The facility sketches for both locations do not have room dimensions. Include all doors, windows, and exits. The facility sketches for Makade located at Manchester Circle Corona; CA does not show windows. D Staff Plan STRTP ILS Sections 87022, 87065, 87065.1, 87065.2, 87065.5, 87078.2, 87095.65-Standard Not Met · Page 73 under In-Service Training and Continuing Education references the incorrect ILS regulations for staff training mandates. Update to include the correct ILS regulation is ILS 87065. Annual Training Plan 87065.1(e) · Partially Missing (Page 88). The annual training must at minimum include all the topics as outlined in ILS 87065.1(e)(3)(A-F) . ILS asks for facility to ensure specific courses are available within the annual training: Missing courses include sexuality, educational needs of youth, & procedures for ensuring a harassment free environment for foster youth & oversight of psychotropic medications. · Describe how the annual training will be verified and documented in the personnel record for each direct care staff ILS 87065.1(e)(6)(A) and 87065.1(e)(7). · Within the annual training plan, include that the Annual training is in addition to first aid and CPR training, and other training as required in Section 87095.65 and ILS 87065.1(e)(8)(A). (Continued on LIC C) Facility Manager Training ILS 87065.1(b) · Page 88 of the Facility Manager Training Plan include or references all the required training as listed ILS 87065.1(b)(5)(A)-(M) the trainings listed do not corresponds the facility manager training listed under 87065.1(b)(5)(A)-(M) · See Best Practice Note-Facility Manager organization Training for Peer Partners and Volunteers 87065.1(f) (1)-(2), 87065.1(g)(1)-(2) : · If using peer partners and/or volunteers, provide, as part of the training plan, the training requirements and the minimum training as outlined, including timelines for completion. ILS 87065.1(f)(1)-(2) and 87065.1 and 87065.1(g)(1)-(2). Specify the requirements that must be met before peer partners and volunteers are allowed to work with the children in care ILS 87065.1(f)(1) and ILS 87065.1(g)(1). · Page 76 under Timelines for Completion include the provision that prior to working with children a peer partner shall be certified in cardiopulmonary resuscitation (CPR) and first aid as stipulated in 87065.1(f)(1). Also include that both peer partners and volunteers are required to receive 16 hours of training on all the topic listed under 87065.1 (f)(1)(A)-(E) for peer partners and 87065.1 and 87065.1(g)(1)(A)-(E) for volunteers. · Page 76 under Timelines for completion include within 90 days of starting peer partners and volunteers must complete an additional 16 hours of training in the following topics as listed under 87065.1(f)(2)(A)-(F) for peer partners and 87065.1(g)(2)(A)-(F) · Page 76 under Documentation and Personnel Records remove the reference to ILS 87065.1(f) and (g) as this section of the ILS makes no refence to documentation for peer partners and volunteers E. Policies Regarding Child Abuse/Neglect Reporting STRTP ILS Section 87022-Standard Met F. Administrative Policies and Procedures STRTP ILS Sections 87022, 87063- Standard Met G. Admission Determination Procedures STRTP ILS Sections 87022, 87068.05-Standard Met (Continued on LIC C) H Intake Policies and Procedures Title CCR Sections 80069, 80070; STRTP ILS 87022, 87068.1, 87068.11, 87068.12, 87078.2 87068.5-Standard Not Met · Page Requirements and Procedures Upon Admittance correct the referenced ILS section ILS 87070(b)(1)-(14) to ILS 87070(b)(1)-(19) Page Requirements and Procedures Upon Admittance correct the referenced ILS section ILS 87070(b)(1)-(14) to ILS 87070(b)(1)-(19) Intake Procedures for Non-Minor Dependents (NMD) Page 147-151 · Include all the required intake information the facility will request/ obtain from the placement agency as listed in ILS 87068.11(f)(2)(A)-(E): . The Health and Education Passport within 48 hours of placement . Any Need and Services Plan (NSP) . The Transitional Independent Living Case Plan . The Transitional Independent Living Plan . The assessment made by the Qualified Individual. · Page Under Emergency Admission of Non-Minor Dependents Include policy and procedures when a non minor dependent is accepted under emergency circumstances ILS 87068.11(h)(1)-(2) a nonminor dependent is placed in the facility under emergency circumstances, a licensee shall ensure the following requirements are met: . Placement of the non-minor dependent in the facility may not result in the facility exceeding its licensed capacity . No later than 30 days following the emergency placement, the administrator or social work staff shall: .Obtain intake information about the non-minor dependent as specified in subsection (f)(1) . Request intake information about the non-minor dependent as specified in subsection (f)(2). .Complete the needs and services plan for the non-minor dependent as specified in subsection (f)(3). I. Admission Agreement Title CCR Sections 80018, 80068; STRTP ILS Sections 87022, 87068.1, 87068.11, 87095.22- Standard met J. Removal and/or Transfer Policies and Procedures ILS Sections 87022, 87061, 87068.4, 87068.11- Standard Not Met · Page Under Development of the Removal and/or Transfer Plan Include the removal and/or transfer procedures for NMD that fully comply with all the requirements of ILS 87068.4(g)(1)-(2) If a non-minor dependent transfers from the facility for other reasons, a licensee shall · Provide written notice to the non-minor dependent that they will transfer from the facility. · State the reason for the transfer of the non-minor dependent, including specific facts about any circumstance or event that resulted in the pending transfer of the non-minor dependent. · Provide a copy of the written notice via e-mail, fax, or overnight mail to the placement agency on the same day the notice is provided. · Page 190 under Documentation and Accountability correct the referenced ILS section 87068.4(g)-(h) to 87068.4(h)(2) and 87070. K Rate Setting and Refunds Policy STRTP ILS Section 87022-Standard Met L Handling of the Child's Money, Personal Property, and/or Valuables Title CCR Sections 80025, 80026; STRTP ILS Sections 87022, 87026- Standard Not Met · Policies and procedures ensuring that cash resources are not taken from the child in the form of fines. · Page 197 include policy and procedures for maintaining receipts Title CCR 80026 (h)(1)(A)-(C) · Page Policy and procedures for cash resources entrusted to the licensee and not kept in the licensed facility shall be deposited in any type of bank, savings and loan, or credit union account meeting the following requirements Title CCR 80026 (i)(1)-(4). Update to include the requirement that the licensee shall provide access to the cash resources upon demand by the client or his/her authorized representative. (Continued LIC C) ·Page Policy and procedures that address how all cash resources, personal property and valuables are handed upon the death of a client Title CCR 80026(I)(1)-(4) · Page Policy and procedure regarding all monetary gifts and of any other gift exceeding an estimated value of $100, provided by or on behalf of a client to the licensee, administrator or staff Title CCR 80026 (n)(1)-2). This does not apply to deceased clients M Consultant and Community Resources Utilized ILS Section 87022 -Standard Met N Trauma Informed and evidenced based interventions STRTP ILS Section 87022- Standard Met O. Plan for Use of Delayed Egress Devices Title CCR Section 80020; STRTP ILS Section Standard met · The facility does not plan to use delayed Egress Devices P. Conflict Of Interest Mitigation Plan STRTP ILS Section Standard Met · This section is not applicable as Makade will not be a county run facility Q Continuous Quality Improvement (CQI) STRTP ILS 87022, 87068.3, 87081- Standard Met Program Statement Populations to Served ILS Section 87022. Standard Met Makade #1 will serve male children ages 10-17 and male non-minor dependents Makade #2 will serve female children ages 10-17 and non-minor dependents 2. Emergency and Disaster Response Services ILS Section 87022.1; Title CCR Section Standard met 3. Transportation Arrangements STRTP ILS Sections 87022.1, Standard Met · See Best Practice note: Clarification is needed regarding the policy on non-minor dependent transportation (Continued on LIC C) 4. Core Supports and Services ILS Sections 87022.1, 87078. Standard met 5. Trauma Informed Interventions and Treatment Practices STRTP ILS Sections 87022.1, 87078.2, 87089.2-Standard Met Licensed Nursing Staff ILS Sections 87022.1, 87089. Standard met Development, Implementation and, Modification of Needs and Services Plans STRTP ILS Sections 87022.1, 87068.2, 87068.22, 87078. Standard met Planned Activities STRTP ILS Sections 87022.1, 87065, 87067, 87068.2, 87068.22, 87078, Standard Met · See Best Practice Note 9. Services During Placement and After Discharge STRTP ILS Section 87022. Standard Met 10. Plan for Participation in Child and Family Team (CFT) STRTP ILS Sections 87022.1, 87078. Standard Met Identification of Home-Based Setting and Family-Based Aftercare Support Plan and Aftercare Services ILS Sections 87022.1, 87089.1 -Standard Met Family and Sibling Participation Sections 87022.1, 87070, 87078.1 -Standard Met Complaints and Grievances Sections STRTP ILS Sections 87022.1, 87072.2, 87078.2-Standard Met Participation and Assistance in Initiatives to improve child Welfare System STRTP ILS Section 87022. Standard Met Family Visitation STRTP ILS Sections 87022.1, 87072, 87078.2, Standard Met 16. Personal Rights STRTP ILS Sections 87022.1, 87072, 87072.3, 87078. Standard Met (Continued on LIC C) 17. House Rules for Children and Non-Minor Dependents ILS Sections 87022.1, 87078.2-Standard Met 18. Positive Discipline Policies and Procedures ILS Sections 87022.1, 87065.2, 87072, 87072.1, 87078.2- Standard not met · Page 448 under Staff Responsibilities When Positive Discipline is Applied expand this section to include staff will do when a child is subject to positive discipline, as required in ILS 87072.1(e) to include conditions under which each type of discipline will be used. When a child is subject to positive discipline, a licensee shall do all of the following: . Discuss the reason and need for the licensee to impose a discipline on the child and provide the child with the opportunity to participate in choosing the appropriate form of discipline. . Document the decision to subject the child to the chosen form of discipline and the steps taken in subjecting the child to the form of discipline. . Develop a plan, including time limit, with the child to be subject to and comply with the chosen form of discipline that is trauma-informed, culturally relevant, and age and developmentally appropriate. · See Best Practice Notes Expectations and Consequences for Non-Minor Dependents ILS Sections 87022.1, 87072.11, and 87078. Standard Met Expectations and Consequences for Non-Minor Dependents ILS Sections 87022.1, 87072.11, and 87078. Standard Not Met · Partially missing- Include a provision that he signed copies of such policies and procedures (for the NMD) shall be maintained in the nonminor dependent's record, as specified in ILS 87070.1(d)(11). 20. Storage of Medications Title CCR Section 80075; STRTP ILS Sections 87022.1, Standard Met (Continued on LIC C) Safeguards for Cash Resources, Personal Property, and Valuables ILS Sections 87022.1, Standard Met Children's Direct Input ILS Sections 87022.1-Standard Met Documentation of Accreditation ILS Sections 87018, 87022.1, 87089-Standard Met · This section meets standards as a short-term residential therapeutic program shall have up to 24 months from the date of provisional licensure to obtain accreditation ILS 97089(b). However, if the applicant has started the accreditation process, the applicant shall submit documentation of accreditation, a copy of its application for accreditation, or a declaration of accreditation status with its application for licensure ILS 87089(c) Mental Health Program Approval ILS Sections 87022.1, 87089.1- Standard Met · See Best Practice Note Food and Nutritional Plan/Sample Menus/Schedule Title CCR Section 80076; STRTP ILS Sections 87022.1, 87070-Standard Met Emergency Intervention Plan (Including Runaway Plan) ILS Sections 87001, 87022.1, 87061, 87063, 87072, 87072.1, 87072.11, 87078.2, 87095.00, 87095.01, 87095.22, 87095.23, 87095.24, 87095.61, 87095.65, 87095.68, 87095.69]-Standard Met Emergency Intervention Plan-Standard met · See Best Practice Notes (Continued on LIC C) Best Practices Plan of Operations B. Administrative Organization -Standard not Met · Page 22 under Required Qualifications for Direct Care Support/Child Care Worker number 7 includes a typo referencing Administrator training that needs to be corrected to reference Direct Care Support/Child Care Worker or removed. · Page 31 under Required Qualifications for the Facility Manager number 7 includes a typo referencing Administrator training that needs to be corrected to reference Facility Manager training or removed · Page 34 under Required Qualifications for the Health, Safety Technical and Building Maintenance Supervisor number 9 includes a typo referencing Administrators that needs to be corrected to reference Health, Safety Technical and Building Maintenance Supervisor or removed · Page 35 under Required Qualifications for the Intensive Care Coordinator number 20 includes a typo referencing Administrator training that needs to be corrected to reference Intensive Care Coordinator or removed. · Page 42 under required qualifications for the Mental Health Rehabilitation Specialist number 7 includes a typo referencing Administrator training that needs to be corrected to reference Mental Health Rehabilitation or removed. · Page 43 under Required Qualifications for Peer Partners number 7 includes a typo referencing Administrator training that needs to be corrected to reference Peer Partners or removed. · Page 46 under Required Qualifications for Psychiatrist number 10 includes a typo referencing Administrator training that needs to be corrected to reference Psychiatrist or removed. · Page 48 under Additional Preferred Qualifications for Social Worker number 5 includes a typo referencing Administrator training that needs to be corrected to reference Social Workers or removed. · Page 51 under Required Qualifications for Volunteers number 5 includes a typo referencing Administrator training that needs to be corrected to reference Volunteers or removed. (Continued on LIC C) NOTE: All short-term residential therapeutic programs shall have a qualified and currently certified administrator ILS 87064(b) NOTE: Work experience in juvenile dentation or an adult correctional facility, juvenile/criminal justice are not identified in the regulations as meeting the educational/experience requirements for Social Workers D Staff Plan STRTP ILS Sections 87022, 87065, 87065.1, 87065.2, 87065.5, 87078.2, 87095.65 · Within this section, it is recommended that a training matrix be arranged in a way that clearly shows staff (specify role and position) that must attend the training, including the following for each training as outlined in ILS 87065.1(b)(2), ILS 87065.1(c)(4) · Additional information on the Facility Manger Training Plan is found on page 84; for organizational purposes it is recommended that the Facility Manger Training information be combined in one section. Best Practices Program Statement 3. Transportation Arrangements STRTP ILS Sections 87022.1, Standard not Met Page Transportation Polices for non-minor dependents explain/expound upon why non-minors would not be transported by staff? Are non-minor dependents to solely rely on public transportation, their own vehicles or use of approved alternate/third party transportation. This contradicts the stated policy on page 241 that stated "MBS guarantees transportation... If this is a typo, please remove and describe arrangements for transporting children/NMDs including to and from health-related services, school, and extracurricular, personal enrichment, cultural, racial, ethnic, and social activities in accordance with the reasonable prudent parent standard specified in Section 87067. Planned Activities STRTP ILS Sections 87022.1, 87065, 87067, 87068.2, 87068.22, 87078, Standard Met · Youth Participation in Planning, Selecting, Conducting, and Evaluating Activities and Culturally Relevant, Trauma Informed Activities are duplicated on pages 307 and 312. This information can be addressed in one section please remove the duplicate information. 18. Positive Discipline Policies and Procedures ILS Sections 87022.1, 87065.2, 87072, 87072.1, 87078.2-Stndard not met · Page 451 expand this section Include a description of how discipline policies account for specialized populations (CSEC youth). CSEC youth" . Describe how MBC is committed to protecting youth from exploitation and prioritizes safety this can include, but not limited to the following: . Emphasis on safety, de-escalation rather than punishment . Expand to describe how safety plans will be developed with CSEC youth that algin with their treatment goals . Describe what the trauma-support strategies MBC will use to aide CSEC youth and how will these strategies be implemented proactively . How will staff address and/or respond to behaviors with an understanding of trauma triggers and how staff will address the underlying causes before implementing positive discipline strategies. Mental Health Program Approval ILS Sections 87022.1, 87089.1- Standard Met · MBC mentions throughout this section that they are contracted with the Riverside University Health System Behavioral Health (RUHS-BH). Please include a copy of the contract/MOU. If not contracted, please revise this language. Recommend changing the language around this. Emergency Intervention Plan (Including Runaway Plan) ILS Sections 87001, 87022.1, 87061, 87063, 87072, 87072.1, 87072.11, 87078.2, 87095.00, 87095.01, 87095.22, 87095.23, 87095.24, 87095.61, 87095.65, 87095.68, 87095.69]- Standard Met · Page 537 and 538 possible typo states that the Nurse will be responsible for the notification of the runway youth. If this is a typo, please correct to reference the correct staff member that will make the notification · Page 541 mentions the Clovis Police Department may be utilized to search for runaway youth. This appears to be a typo as neither Makade location is in the city of Clovis. Please update this information to reference the correct police department/agency. This report was emailed to CEO Jorge Cervantes for signature. The original, signed reports will be placed in the facility file.

met_with: Chief Operating Officer Jorge Cervantes and Director Akila Crane