summary: Facility Evaluation

raw_content:
Narrative:
On 11/07/2023 at 10: AM Licensing Program Analyst LPA Rosslyn Gray made an unannounced to HASKELL TEMPORARY SHELTER CARE FACILITY (TSCF) to conduct Annual/Required. Prior to entering the facility LPA conducted a Heath and Safety Risk assessment. LPA met with the Lead Direct Care Staff who granted access to the facility who granted access into the home and provided a tour of the entire physical plant inside and out. The facility is to provide Temporary Shelter Care Services up to Days to six (6) males ages 13-17 years; Ambulatory only and there is a Naloxone Waiver on File. There are currently no clients in placement. There are no bodies of water on the premises. The staff confirmed that there are no guns or weapons on the premises. LPA-Gray observed the follow during the inspection: TSCF Overview: This is a one (1) story 3 bedrooms 2 bath home located in a residential neighborhood. There a living room, dining room, kitchen, staff office and a two (2) car garage. Currently there is not a vehicle utilized to transport the children. Staff has valid drivers license and covered by County of Los Angeles Risk Management Branch. Outdoor Area: The activity space is free of hazard materials and debris. LPA observed a staff displayed the utility shut-off valves for gas and water. The Hot Water Heater is enclosed in the basement on the side of the house. LPA observed all windows, screens and drapes from the inside and outside of the facility were observed to be in good condition. There is mounted basketball court, a barbecue pit, and several lemon trees and a black metal picnic table. The passageways and porches are unobstructed. All posting requirements were met, (food menu, regulations, emergency disaster plan is inside the office, kitchen are posted throughout the facility). In the dining area there are Grievance forms and a comment box mounted the wall. LIC- Page 1 of The two (2) car garage utilized for extra storage, water, food supply and (PPE) Personal Protection Equipment. There are two (2) freezers and water bottles. The cleaning supplies solutions, disinfectants are stored in the staff office. The sharp knives are also inaccessible in separate box in the key locked cabinet. LPA observed a hard wired enter connected combined Smoke detector and Carbon Monoxide; tested to be operable. The Living Room is equipped with two sofas a desk and a chair. Currently there is not a television due to recently being damaged and the Administrator is in the process of purchasing a new television for the children's entertainment. Dining room/Kitchen: Observed to be clean and organized; There is five (5) burner gas stove; a double door refrigerator top freezer.The is also a full freezer and a refrigerator located in the garage. The dining table has six (6) chairs. There is book shelf and a cabinet for art supplies and games. LPA observed coverage trash cans in the kitchen. The laundry room is in the hallway equipped with a washer and dryer, and linen closet is above the washing machine. LPA observed two (2) Fire Extinguishers located in staff office to prevent children for using it as weapon. There are three (3) Bedrooms: Each bedroom is equipped with two (2) twin size beds, a mattresses, clean linen, blankets, adequate drawer space and one (1) walk in closet, sliding windows and drapes; observed to be in good condition. The personal rights are posted on the back of each bedroom door. Each bedroom has individual foot lockers the children's to lock and staff has stored in the staff office. Bedroom # 1: Is currently unoccupied Bedroom # 2: Is currently unoccupied Bedroom # 3: Is the Master Bedroom. Is currently unoccupied. There a walk-in closet and walk in full-size bathroom with 2 sinks. LIC- Page 2 of Bathrooms: There are two (2) full sized bathrooms were inspected and found to be clean. Bathroom #1 is in the Hallway and Bathroom #2 is in the Bedroom #3. LPA ensured that all toilets flushed, and tested water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. There is a staff office equipped with office furniture. There is a small refrigerator utilize to store medication that require to be refrigerated. All the children's prescribed medications; medication logs, files and medical devices are locked key entry. The First Aid kit kept in the staff office in locked cabinet. It was observed to be equipped with the required items inside (age-appropriate, and scissors, tweezers, thermometer, and gauzes, antiseptic and First Aid Manual Guide. The facility has a working telephone and children can use the telephone unless restricted by court order. Based on the behavior, compliance and the children's trauma staff selectively accompany clients to local recreational facilities. Children are accorded dignity in personal relationships with staff and others. LPA observed that facility continues to ensure that the CDC Guidelines are implemented in effort to prevent other from contracting the COVID-19 virus (i.e wash hands with alcohol based hand sanitizer, display colorful preventative hygiene poster, disinfect commonly used areas and items (remote controls, mouse's, playing, cards cell phones, practice "cough etiquette"). The facility will operate within license conditions and limitations that include capacity limitations. The facility personnel are instructed to report violations of personal rights. Licensee will report changes in the plan of operation affecting service to children that include maintenance damages and repairs. Licensee will report client injuries requiring medical treatment. LPA observed and reviewed staff's certification of training requirements, from the Public Health Dept and In house training, (i.e De-escalation, the Dangers of Fentanyl, psych meds, substance abuse prevention, Response to Child Fatalities, etc). The administrator will provide the Personnel Report (LIC 500) and confirmed that the ratio present for the capacity of children in placement. The administrator will ensure that all staff have required criminal record clearance, DOJ, FBI and Child Abuse Response that will meet qualification and associated to the facility. There were no deficiencies cited at this time. LPA concluded the Annual/Required Inspection. An exit interview was conducted, and a copy of this report was left at the facility with the Administrator on 11/07/ LIC- Page 3 of 3

met_with: LEAD DIRECT CARE STAFF


state: CA

facility_name: TSCF HASKELL

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Olivia Rosas conducted a case management inspection March 6, 2024, at 10:30am based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 5 out of Direct Care Staff and 2 out of 2 youth files were reviewed. In the inspection, 3 out of Direct Care Staff and 0 out of 2 youth were interviewed (See the Confidential Names List, LIC 811, dated March 6, 2024). The Plan of Operation including policies and procedures were reviewed. Minutes from a meeting related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the youth case plans, support plan, emergency access & placement referral form (DCFS6017), and foster child's needs and case plan summary (DCFS709), the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Rosas observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance with their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to House Manager, Janet Jackson.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Regina Goree, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 11/07/2024 at 10:30AM Licensing Program Analyst LPA Rosslyn Gray made an unannounced to HASKELL TEMPORARY SHELTER CARE FACILITY (TSCF) to conduct Annual/Required Inspection. Prior to entering the facility LPA conducted a Heath and Safety Risk assessment. LPA met with the House Manager Janet Jackson who granted access into the facility and provided a tour of the entire physical plant inside and out. The facility is to provide Temporary Shelter Care Services up to Days to six (6) males ages 13-17 years; Ambulatory only and there is a Naloxone Waiver on File. Currently there are no clients in placement. There are no bodies of water on the premises. The staff confirmed that there are no guns or weapons on the premises. LPA-Gray observed the follow during the inspection: TSCF Overview: This is a one (1) story 3 bedrooms 2 bath home located in a residential neighborhood. There is a living room, dining room, kitchen, staff office and a two (2) car garage. Currently there is not a vehicle utilized to transport the children. Staff has valid drivers license and covered by County of Los Angeles Risk Management Branch. Outdoor Area: The activity space is free of hazard materials and debris. LPA observed a staff display the utility shut-off valves for gas and water on the side of house. The Hot Water Heater is enclosed in the basement on the left side of the house. LPA observed all windows, screens and drapes from the inside and outside of the facility were observed to be in good condition. There is mounted basketball court, a barbecue pit, and several lemon trees and a black metal picnic table. The passageways and porches are unobstructed. All posting requirements were met, (food menu posted on side of the refrigerator) personal rights (posted on the kitchen wall), regulations, emergency disaster plan are posted on the wall inside the office, kitchen are posted throughout the facility). LIC- Page 1 of The two (2) car garage utilized for extra storage, water, ample food supply, clothing, bedding and (PPE) Personal Protection Equipment. There are two (2) freezers and water bottles. The cleaning supplies solutions, disinfectants are stored in the staff office. The sharp knives are also inaccessible in separate box in the key locked cabinet. LPA observed a hard wired enter connected combined smoke detector and Carbon Monoxide; tested to be operable. The Living Room is equipped with one (1) sofa, one love seat(1), a desk, table, 2 chairs chair, a 45' television. There is a cable box powered by SPECTRUM for clients to access basic channels. Dining room/Kitchen: Observed to be clean and organized; There is newly installed five (5) burner gas stove; a double door refrigerator top freezer.The is also a full freezer and a refrigerator located in the garage. The dining table has six (6) chairs. There is book shelf and a cabinet for art supplies and games. LPA observed coverage trash cans in the kitchen. The laundry room is in the hallway equipped with a washer and dryer, and linen closet is above the washing machine. LPA observed three (3) fully charged Fire Extinguishers located in staff office to prevent clients from using it as a weapon. There are three (3) Bedrooms: Each bedroom is equipped with two (2) twin size beds, a mattress, clean linen, blankets, adequate drawer space and one (1) walk in closet, sliding windows and drapes; observed to be in good condition. The Youths Foster Rights, are posted on the back of each bedroom door. Bedroom # 1: Is currently unoccupied Bedroom # 2: Is currently unoccupied Bedroom # 3:Is currently unoccupied Bathrooms: There are two (2) full sized bathrooms were equipped with a tube, shower, sink., inspected and found to be clean. Bathroom #1 is in the hallway and bathroom #2 is located in the staff office. LPA ensured that all toilets flushed, and the water was tested, temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. LIC- Page 2 of Staff Office: Is equipped with office furniture, two (2) desk, a small chair, a locked metal cabinet that stores, Albuterol Inhaler, EpiPen, and Naloxone. There is a small refrigerator utilize to store medication that require to be refrigerated. All prescription medications; medication logs, files and medical devices are locked inside the supply closet with a key entry. The First Aid kit kept in the staff office in locked cabinet; observed to be equipped with the required items inside (age-appropriate, and scissors, tweezers, thermometer, and gauzes, antiseptic and First Aid Manual Guide. The facility has a working telephone available for clients use the telephone unless restricted by court order. Based on the behavior, compliance and the client's trauma; staff will selectively accompany clients to local recreational facilities. Clients are accorded dignity in personal relationships with staff and others. LPA observed that facility continues to ensure that the CDC Guidelines are implemented in effort to prevent other from contracting the COVID-19 virus (i.e wash hands with alcohol based hand sanitizer, display colorful preventative hygiene poster, disinfect commonly used areas and items (remote controls, mouse's, playing, cards cell phones, practice "cough etiquette"). The facility will operate within license conditions and limitations that include capacity limitations. The facility personnel are instructed to report violations of personal rights. The Licensee will report changes in the plan of operation affecting service to clients that include maintenance damages and repairs. Licensee will report client injuries requiring medical treatment. LPA observed and reviewed staff training requirements, In house training on a transcript, Crisis Prevention Institute training (CPI) (i.e De-escalation, the Dangers of Fentanyl, psych meds, substance abuse prevention, Response to Child Fatalities, etc). The Facility Manager provided the Personnel Report (LIC 500) and confirmed that the ratio is present for the capacity of clients in placement. The Facility Administrator will ensure that all staff have required criminal record clearances, DOJ, FBI and Child Abuse Response that will meet qualification and associated to the facility. There were no deficiencies cited at this time. LPA concluded the Annual/Required Inspection. An exit interview was conducted, and a copy of this report was left at the facility with the Facility Manager Janet Jackson on 11/07/ LIC- Page 3 of 3

visit_type: Annual

met_with: FACILITY MANAGER JANET JACKSON


summary: Facility Evaluation

raw_content:
Narrative:
On November 7, 2023, at 9: AM, Licensing Program Analyst (LPA), Rosslyn Gray and Licensing Program Manager (LPM), JoAunne Griffin arrived at the above facility for the purpose of conducting a Case Management - Incident. On November 6, 2023, the Department received an Emergency Response Referral Information, dated November 5, 2023. Emergency Response Referral Information indicates that C#1 was hospitalized on November 2, 2023, after being found unresponsive. C#1 passed away on November 5, 2023. During the investigation process, LPA interviewed related parties and reviewed Incident Reports. Statements indicated that C#1 went on an unauthorized absence on October 16, 2023, and bed was closed on October 18, 2023. Information obtained indicated that although an Incident Report was completed by facility staff, it was not forwarded to Community Care Licensing Division (CCLD) for review. Facility cited for violation of Interim Licensing Standards TSCF, Section 84661 (e)(1) Reporting Requirements. Facility did not report unauthorized absence of C#1. An exit interview was conducted. A copy was left at the facility with the Heather Wolfe, Lead Direct Care Staff

met_with: Heather Wolfe, Lead Direct Care Staff


facility_name: TSCF WILBUR

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Documentary interviews and evidence also confirm that emergency services were contacted, both alleged victims were evaluated and one(1) alleged victim refused to be transported to the hospital. Due to lack of evidence obtained during the investigation, LPA determines that the allegations of Neglect/Lack of Supervision, and Personal Rights are Unsubstantiated at this time meaning, although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. There are no deficiencies cited at this time. An exit interview was conducted, and a copy of this report was left at the House Administrator.

Investigation Findings:
13On February 17,2023 at 12: Licensing Program Analyst (LPA), Rosslyn Gray made an unannounced visit to conclude the investigation and to deliver the findings. During the investigation. LPA-Gray interviewed and accounted for all available relevant parties; and gathered pertinent information in reference to the allegations. The Licensee denied the allegations. Based on confidential interviews and review of documentary evidence, there is no evidence or witnesses to support that "Staff did not prevent minors from engaging in CSEC activity; Staff did not prevent minors from engaging in a physical altercation; Minor was bit by another minor in care; and that the staff did not seek medical attention for minor". Documentary interviews were congruent that staff followed protocol, proper supervision and methods of crisis communication were implemented for their health and safety, to prevent the minors from engaging in CSEC activity. iTrack Special Incident Reports-(SIRs) were written and submitted within the proper time frame and authorized representatives were notified. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Rosslyn Y. Gray LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: TSCF WILBURFACILITY NUMBER: VISIT DATE: 02/17/2023

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

report_type: Complaint Investigation

met_with: House Manager

complaint_status: unsubstantiated


summary: Facility Evaluation

raw_content:
Narrative:
On 12/03/2021 at 4: PM Licensing Program Analyst (LPA's) Rosslyn Gray made an unannounced to WILBUR TEMPORARY SHELTER CARE FACILITY (TSCF) to conduct Pre-Licensing Inspection. LPA met with the administrator who granted access to the facility. The entire physical plant was inspected. The facility is to provide Temporary Shelter Care Services up to Days, to six (6) males ages 13-17 years; Ambulatory only. There are no bodies of water on the premises. The Administrator confirmed that there are no guns or weapons on the premises. LPA- Gray observed the follow during the inspection: TSCF Overview: This is a 1-story, 3 bedrooms; 2-bathroom home located in a residential neighborhood. There a living room, dining room, kitchen, staff office and a two (2) car garage. Currently there is not a vehicle utilized to transport the children. The administrator will provide information about the company vehicle later to be inspected to be operating in good condition. Outdoor Area: The activity space is free of hazard materials and debris. LPA observed the utility shut-off valves for gas and water located in front of the facility. The Hot Water Heater is enclosed in the garage adjacent to the washer and dryer. LPA observed all windows, screens and drapes from the inside and outside of the facility were observed to be in good condition. There is mounted basketball court, and several trees and a two (2) black metal picnic tables. The passageways and porches are unobstructed. All posting requirements were met, (food menu will be posted prior to the children being placed, regulations, emergency disaster plan is kept inside the office. The personal rights are all posted on the back of each bedroom doors. In the dining area there is Grievance forms and a comment box mounted the wall. The two (2) car garage utilized for extra storage, water, food supply and (PPE) Personal Protection Equipment. The facility keeps an inventory of the PPE supplies and to report when they are depleted. There are two (2) freezers, water bottles and Ping Pong table. The Licensee will ensure that the children are always monitored when children are in the garage area. The door entrance to the garage from the kitchen is key locked for precautionary measures. The cleaning supplies solutions, disinfectants are stored in the staff office. The sharp knives are also inaccessible in separate box in the key locked office. LPA observed a hard wired enter connected combined Smoke detector and Carbon Monoxide; tested to be operable. The Living Room is fully furnished with a sofa; two (2) large lounge chairs, two (2) televisions, and one (1) red cabinets to store electronic games; a computer monitors and computer desk. Dining room/Kitchen: Observed to be clean and organized; The Kitchen stove is gas operated with 5 burners; the oven is separate from stove. There is a double door refrigerator with upper freezer. The is also an additional freezer located in the garage. The dining table has six (6) chairs. There is book shelf and art supplies. LPA observed coverage trash cans in the kitchen, bathroom and staff office. The laundry room is in the garage quipped with a washer and dryer. The detergent will be distributed according the individual load of clothing. LPA observed ample linen in the linen closet locate in the hallway. LPA observed two (2) Fully Charged Fire Extinguishers located in the kitchen and in the staff office fully charged. There are three (3) Bedrooms: Each bedroom twin size beds, with a mattress, clean linen, adequate clothes and drawer space. Bedroom # 1: Is currently unoccupied equipped with two (2) twin sized beds, comfortable mattresses, linen, blankets and pillows; adequate drawer and one (1) walk in closet. There is adequate lighting and the windows and drapes; observed to be in good condition. Bedroom # 2: Is currently unoccupied equipped with two (2) twin sized beds, comfortable mattresses, linen, blankets and pillows; adequate drawer and one (1) walk in closet. There is adequate lighting and the windows, drapes; observed to be in good condition. Bedroom # 3: Is currently unoccupied equipped with two (2) twin sized beds, comfortable mattresses, linen, blankets and pillows; adequate drawer and one (1) walk in closet. There is adequate lighting and the windows, drapes; observed to be in good condition Bathrooms: There are two (2) Bathrooms were inspected and found to be clean. Bathroom #1 is a full-sized Bathroom (sink, toilet shower and tube)., located in hallway. Bathroom #2 is a Half bath with a sink toilet and a shower. LPA ensured that all toilets flushed, and tested water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. There is a staff office equipped with office furniture. There is a small refrigerator utilize to store medication that require to be refrigerated. All the clients prescribed medications; medication logs, files and medical devices are locked key entry. The First Aid kit kept in the staff office. It was observed to be equipped with the required items inside (age-appropriate, and scissors, tweezers, thermometer, and gauzes, antiseptic and First Aid Manual Guide. The facility has a working telephone and clients can use the telephone unless restricted by court order; in addition, for the authorized representatives to make contact. The staff will accompany clients to local recreational facilities based on the rules of the COVID-19. Clients are accorded dignity in personal relationships with staff and others. LPA observed that facility ensures that CDC Guidelines are implemented in effort to prevent other from contracting the COVID-19 virus (i.e wash hands with alcohol based hand sanitizer, display colorful preventative hygiene posters, temperature checks, maintain social distancing (six feet of space), disinfect commonly used areas and items (remote controls, mouse's, playing, cards cell phones, practice "cough etiquette". The Facility will operate within license conditions and limitations including capacity limitations. The Administrator ensured the facility will have the written plan of operation. Facility personnel are instructed to report violations of personal rights. Licensee will ensure report changes in the plan of operation affecting service to clients. Licensee will ensure to report client injuries requiring medical treatment. The administrator will provide the Personnel Report (LIC 500) and confirmed that the Ratio present for the six (6) clients in placement. The administrator ensured that all will have required criminal record clearance. DOJ, FBI and Child Abuse Response that will meet qualification. There were no deficiencies cited at this time. LPA's concluded the Pre-License Inspection. An exit interview was conducted, and a copy of this report was left at the facility with the Administrator on 12/03/2021

visit_type: Prelicensing

met_with: Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 08/23/2022 at 10: AM Licensing Program Analyst (LPA) Rosslyn Gray made an unannounced to WILBUR TEMPORARY SHELTER CARE FACILITY (TSCF) to conduct Post Licensing Inspection. A Health and safety risk assessment was conducted upon arriving at the facility. LPA met with the Administrator who granted access to the facility. The entire physical plant was inspected. The facility is to provide Temporary Shelter Care Services up to Days, to six (6) children ages 13-17 years; Ambulatory only. There are no bodies of water on the premises. The staff confirmed that there are no guns or weapons on the premises. LPA- Gray observed the follow during the inspection: TSCF Overview: This is a 1-story, 3 bedrooms; 2-bathroom home located in a residential neighborhood. There a living room, dining room, kitchen, staff office and a two (2) car garage. There is vehicle utilized to transport the children. The staff will provide information about the company vehicle later to be inspected to be operating in good condition. Outdoor Area: The passageways and porches are unobstructed. The activity space is free of hazard materials and debris. LPA observed the utility shut-off valves for gas and water located in back yard side of the of the facility. LPA observed all windows, screens and drapes from the inside and outside of the facility were observed to be in good condition. There is mounted basketball court, and several trees and a one (1) black metal picnic tables and a Barbecue Pit. LPA observed coverage trash cans in the kitchen, bathrooms and staff office. All posting requirements were met, (food menu posted on the refrigerator; regulations, emergency disaster plan is kept inside the office. In the dining area there is Grievance forms and a comment box mounted the wall. The Hot Water Heater is enclosed located the hallway in between bedrooms 1 and 2. The two (2) car garage The door entrance to the garage from the kitchen is key locked for precautionary measures. There is a space for laundry units washer and dryer. The detergent is distributed according the youths individual load of clothing. The Licensee will ensure that the children are always monitored when children are in the garage area. The garage is also utilized for extra storage, water, food supply and (PPE) Personal Protection Equipment. The facility keeps an inventory of the PPE supplies and to report when they are depleted. There are two (2) freezers, water bottles and Ping Pong table. LPA observed extra clothing donated by a church that is being organized separated by gender. Staff office: Is equipped with office furniture. There is a small refrigerator utilize to store medication that require to be refrigerated. All the clients prescribed medications; medication logs, files and medical devices are locked key entry. The cleaning supplies solutions, disinfectants are stored in the staff office. The sharp knives are also inaccessible in separate box in the key locked office.The First Aid kit met requirements, (age-appropriate, and scissors, tweezers, thermometer, and gauzes, antiseptic and First Aid Manual Guide). The facility has a working telephone and clients can use the telephone unless restricted by court order; in addition, for the authorized representatives to make contact. LPA observed a hard wired enter connected combined Smoke detector and Carbon Monoxide; tested to be operable. The Living Room is fully furnished with a sofa; two (2) large lounge chairs, one (1) television, red cabinet utilized to store electronic games; a long white computer desk and a monitor. Dining room/Kitchen: Observed to be clean and organized; The Kitchen stove is gas operated with 5 burners; the oven is separate from stove. There is a double door refrigerator with upper freezer.The dining table has six (6) chairs. All required posting are posted on the wall. LPA observed ample linen in the linen closet locate in the hallway. LPA observed two (2) Fully Charged Fire Extinguishers located in the kitchen and in the staff office fully charged. There are three (3) Bedrooms: Each bedroom is equipped with two (2) twin size beds, with a mattresses, clean linen, blankets, adequate drawer space and one (1) walk in closet, sliding windows and drapes; observed to be in good condition. The personal rights are posted on the back of each bedroom door. LIC Page 2 of Bedroom # 1: Is currently occupied by one (1) observed to be in good condition. Bedroom # 2: Is currently occupied by one (1), observed to be in good condition. Bedroom # 3: Is currently unoccupied, observed to be in good condition Bathrooms: There are two (2) Bathrooms were inspected and found to be clean. LPA ensured that all toilets flushed, and tested water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. Bathroom #1 is a full-sized Bathroom (sink, toilet shower and tube)., located in hallway. Bathroom #2 is a Half bath with a sink toilet and a shower, located in the staff office. The staff will accompany clients to local recreational facilities based on the rules of the COVID-19. Clients are accorded dignity in personal relationships with staff and others. LPA observed that facility ensures that CDC Guidelines are implemented in effort to prevent other from contracting the COVID-19 virus (i.e wash hands with alcohol based hand sanitizer, display colorful preventative hygiene posters, temperature checks, maintain social distancing (six feet of space), disinfect commonly used areas and items (remote controls, mouse's, playing, cards cell phones, practice "cough etiquette". The Facility will operate within license conditions and limitations including capacity limitations. The Facility personnel are instructed to report violations of personal rights. Licensee will ensure report changes in the plan of operation affecting service to clients. Licensee will ensure to report client injuries requiring medical treatment. The administrator will provide the Personnel Report (LIC 500) and confirmed that the Ratio present for the six (6) clients in placement. The administrator ensured that all will have required criminal record clearance. DOJ, FBI and Child Abuse Response that will meet qualification. There were no deficiencies cited at this time. LPA's concluded the Post License Inspection. An exit interview was conducted, and a copy of this report was left at the facility with the Administrator on 08/23/2022

met_with: ADMINISTRATOR


summary: Facility Evaluation

raw_content:
Narrative:
On 12/05/2022 at 11: AM Licensing Program Analyst (LPA) Rosslyn Gray made an unannounced to WILBUR TEMPORARY SHELTER CARE FACILITY (TSCF) to conduct a Annual/Required Inspection. A Health and safety risk assessment was conducted upon arriving at the facility. LPA met with the Administrator who granted access to the facility. The entire physical plant was inspected. The facility is to provide Temporary Shelter Care Services up to Days, to six (6) children ages 13-17 years; Ambulatory only. There are no bodies of water on the premises. The staff confirmed that there are no guns or weapons on the premises. LPA- Gray observed the follow during the inspection: TSCF Overview: This is a story, 3 bedrooms; 2 bathroom home located in a residential neighborhood. There is a living room, dining room, kitchen, staff office and a two (2) car garage. There is vehicle provide by the Los Angeles County Children's Residential Fleet Inspected to be operating in good condition. The vehicle is utilized to pick up supplies (i.e food, household cleaning supplies, etc; and the children are transported in the event of and emergency. Staff has authorized to transport children in their personal vehicles. Staff has valid drivers license and covered by by County of Los Angeles Risk Management Branch. Outdoor Area: The passageways and porches are unobstructed. The activity space is free of hazard materials and debris. LPA observed the utility shut-off valves for gas and water located in back yard side of the of the facility. LPA observed all windows, screens and drapes from the inside and outside of the facility were observed to be in good condition. There is mounted basketball court, and several trees and a one (1) black metal picnic tables and a Barbecue Pit. LPA observed coverage trash cans in the kitchen, bathrooms and staff office.All posting requirements were met,(food menu posted on the refrigerator; regulations, emergency disaster plan is kept inside the office. In the dining area there is Grievance forms and a comment box mounted the wall.The Hot Water Heater is enclosed located inside the garage adjacent to washer and dryer unit. The central air conditioning unit is located in the hallway in between bedrooms 1 and 2. The two (2) car garage The door entrance to the garage from the kitchen is key locked for precautionary measures. There is a space for laundry units washer and dryer. The detergent is distributed according the youths individual load of clothing. The Licensee will ensure that the children are always monitored when children are in the garage area. The garage is also utilized for extra storage, water, food supply and (PPE) Personal Protection Equipment. The facility keeps an inventory of the PPE supplies and to report when they are depleted. There are two (2) freezers, water bottles and Ping Pong table. LPA observed extra clothing donated by a church that is being organized separated by gender. Staff office: Is equipped with office furniture. There is a small refrigerator utilize to store medication that require to be refrigerated. All the clients prescribed medications; medication logs, files and medical devices are locked key entry. The cleaning supplies solutions, disinfectants are stored in the staff office. The sharp knives are also inaccessible in separate box in the key locked office. The First Aid kit met requirements, (age-appropriate, and scissors, tweezers, thermometer, and gauzes, antiseptic and First Aid Manual Guide). The facility has a working telephone and children can use the telephone unless restricted by court order; in addition, for the authorized representatives to make contact. LPA observed a hard wired enter connected combined Smoke detector and Carbon Monoxide; tested to be operable. The Living Room is fully furnished with a sofa; two (2) large lounge chairs, one (1) television, red cabinet utilized to store electronic games; a long white computer desk and a monitor. Dining room/Kitchen: Observed to be clean and organized; The gas stove is operated with 5 burners; the oven is separate from stove. There is a double door refrigerator with upper freezer.The dining table has six (6) chairs. All required posting are posted on the wall. LPA observed ample linen in the linen closet locate in the hallway. LPA observed two (2) Fully Charged Fire Extinguishers located in the kitchen and in the staff office fully charged. LIC Page 2 of There are three (3) Bedrooms: Each bedroom is equipped with two (2) twin size beds, with a mattresses, clean linen, blankets, adequate drawer space and one (1) walk in closet, sliding windows and drapes; observed to be in good condition. The personal rights are posted on the back of each bedroom door. Bedroom # 1, BR #2 and BR # Is currently occupied by one (1) child observed to be in good condition. Bathrooms: There are two (2) bathrooms inspected and found to be clean. LPA ensured that all toilets flushed, and tested water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. Bathroom #1 is a full sized Bathroom (sink, toilet shower and a tube)., located in hallway. Bathroom #2 identified as staff bathroom; is a Half bath with a sink toilet and a shower, located in the staff office. This is e shower is not being utilized. The staff will accompany children local recreational facilities based on Monday's and Friday the rules of the COVID-19. LPA observed that facility ensures that CDC Guidelines are implemented in effort to prevent other from contracting the COVID-19 virus (i.e wash hands with alcohol based hand sanitizer, display colorful preventative hygiene posters, temperature checks, maintain social distancing (six feet of space), disinfect commonly used areas and items (remote controls, mouse's, playing, cards cell phones, practice "cough etiquette". The facility will operate within license conditions and limitations including capacity limitations. The facility personnel are instructed to report violations of personal rights. Licensee will ensure report changes in the plan of operation affecting service to children. Children are accorded dignity in personal relationships with staff and others; and the Licensee will ensure to report client injuries requiring medical treatment. The administrator will provide the Personnel Report (LIC 500) and confirmed that the ratio present for the six (6) clients in placement. The administrator ensured that all will have required criminal record clearance. DOJ, FBI and Child Abuse Response that will meet qualification. There were no deficiencies cited at this time. LPA's concluded the Annual/Required Inspection. An exit interview was conducted, and a copy of this report was left at the facility with the House Manager on 12/05/2022


summary: Facility Evaluation

raw_content:
Narrative:
On 6/23/2023 at 1:00pm Licensing Program Analyst conducted an collateral visit at TSCF Wilbur address Wilbur Northridge, CA 91234. LPA met with the Administrator who granted access to the facility. The purpose of the visit is to conduct an interview with C1. A copy of this report was left at the facility with Credell Jackson.

met_with: Credell Jackson, House Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 12/15/2023 at 2: PM Licensing Program Analyst (LPA) Rosslyn Gray made an unannounced visit to WILBUR TEMPORARY SHELTER CARE FACILITY (TSCF) to conduct an Annual/Required Inspection. A Health and safety risk assessment was conducted upon arriving at the facility. LPA met with the House Manager who granted access to the facility. The entire physical plant was inspected. The facility is to provide Temporary Shelter Care Services up to Days, to six (6) children ages 13-17 years; Ambulatory only. There are no bodies of water on the premises. The staff confirmed that there are no guns or weapons on the premises. LPA- Gray observed the follow during the inspection: TSCF Overview: This is a story, 3 bedrooms; 2 bathroom home located in a residential neighborhood. There is a living room, dining room, kitchen, staff office and a two (2) car garage. There is vehicle provide by the Los Angeles County Children's Residential Fleet Inspected to be operating in good condition. The vehicle is utilized to pick up supplies (i.e food, household cleaning supplies, etc; and the children are transported in the event of and emergency. Staff has valid drivers license and covered by by County of Los Angeles Risk Management Branch. Outdoor Area: The passageways and porches are unobstructed. The activity space is free of hazard materials and debris. LPA observed the utility shut-off valves for gas and water located in back yard side of the facility. LPA observed all windows, screens and drapes from the inside and outside of the facility were observed to be in good condition. There is mounted basketball court, and several trees and a black metal picnic table and a Barbecue Pit. LPA observed coverage trash cans in the kitchen, bathrooms and staff office. All posting requirements were met,(food menu posted on the refrigerator; regulations, emergency disaster plan is kept inside the office. In the dining area there is Grievance forms and a comment box mounted the wall. The Hot Water Heater is enclosed located inside the garage adjacent to washer and dryer unit. The central air conditioning unit is located in the hallway in between bedrooms 1 and 2. The two (2) car garage The door entrance to the garage from the kitchen is key locked for precautionary measures. There is a space for laundry units washer and dryer. The detergent is distributed according the youths individual load of clothing. The Licensee will ensure that the children are always monitored when they in the garage area. The garage is also utilized for extra storage, water, food supply and (PPE) Personal Protection Equipment. There are two (2) freezers and a water bottle. Staff office: Is equipped with office furniture. There is a small refrigerator utilize to store medication that require to be refrigerated. All the clients prescribed medications; medication logs, files and medical devices are locked key entry. The cleaning supplies solutions, disinfectants are stored in the staff office. The sharp knives are also inaccessible in separate box in the key locked office. The First Aid kit met requirements, (age-appropriate, and scissors, tweezers, thermometer, and gauzes, antiseptic and First Aid Manual Guide). The facility has a working telephone and children can use the telephone unless restricted by court order; in addition, for the authorized representatives to make contact. LPA observed a hard wired enter connected combined Smoke detector and Carbon Monoxide; tested to be operable. The Living Room is currently furnished with (4) large lounge chairs, one (1) television, red shelf. There is a sofa that has been removed due to damages and in the process of being replaced. Dining room/Kitchen: Observed to be clean and organized; The gas stove is operated with 5 burners; the oven is separate from stove. There is a double door refrigerator with upper freezer.The dining table has six (6) chairs. All required posting are posted on the wall. LPA observed ample linen in the linen closet locate in the hallway. LPA observed two (2) Fully Charged Fire Extinguishers located in the kitchen and in the staff office fully charged. LIC Page 2 of There are three (3) Bedrooms: Each bedroom is equipped with two (2) twin size beds, clean linen, blankets, adequate drawer space and one (1) walk in closet, sliding windows and drapes; observed to be in good condition. The personal rights are posted on the back of each bedroom door. Bedroom # 1, BR #2 and BR #3 currently the bedrooms are not occupied. There are three (3) mattress reportedly that have been damages and in process of being replaced. Bathrooms: There are two (2) bathrooms inspected and found to be clean. LPA ensured that all toilets flushed, and tested water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. Bathroom #1 is a full sized Bathroom (sink, toilet shower and a tube)., located in hallway. Bathroom #2 identified as staff bathroom; is a Half bath with a sink toilet and a shower, located in the staff office. This is also a shower is not being utilized. The staff will accompany children local recreational activities. LPA observed that facility ensures that CDC Guidelines are implemented (i.e wash hands with alcohol based hand sanitizer, display colorful preventative hygiene posters, disinfect commonly used areas and items (remote controls, mouse's, playing, cards cell phones, practice "cough etiquette". The facility will operate within license conditions and limitations including capacity limitations. The facility personnel are instructed to report violations of personal rights. Licensee will ensure report changes in the plan of operation affecting service to children. Children are accorded dignity in personal relationships with staff and others; and the Licensee will ensure to report client injuries requiring medical treatment. The facility provided the Personnel Report (LIC 500) and confirmed that the ratio present for six (6) clients in placement. LPA observed required criminal record clearances that met qualification. There were no deficiencies cited at this time. LPA concluded the Annual/Required Inspection. An exit interview was conducted, and a copy of this report was left at the facility with the House Manager on 12/15/ LIC-809-C Page 3 of 3

met_with: House Manager/Anna Jeong


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Olivia Rosas conducted a case management inspection April 16, 2024, at 10:30am based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 5 out of Direct Care Staff and 1 out of 1 youth files were reviewed. In the inspection, 3 out of Direct Care Staff and 0 out of 1 youth were interviewed (See the Confidential Names List, LIC 811, dated April 16, 2024). The Plan of Operation including policies and procedures were reviewed. Minutes from a meeting related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the youth case plans, support plan, emergency access & placement referral form (DCFS6017), and foster child's needs and case plan summary (DCFS709), the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Rosas observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance with their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to House Manager, Credell Jackson.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/16/2024 a 10:45AM PM Licensing Program Analyst (LPA) Rosslyn Gray made an unannounced visit to WILBUR TEMPORARY SHELTER CARE FACILITY (TSCF) to conduct an Annual/Required Inspection. A Health and safety risk assessment was conducted upon arriving at the facility. LPA met with the House Manager Credell Jackson who granted access to the facility. The entire physical plant was inspected. The facility is to provide Temporary Shelter Care Services up to Days, to six (6) children ages 13-17 years old; Ambulatory only. There are no bodies of water on the premises. S1 confirmed that there are no guns or weapons on the premises. LPA- Gray observed the follow during the inspection: TSCF Overview: This is a story, 3 bedrooms; 2 bathroom home located in a residential neighborhood. There is a living room, dining room, kitchen, staff office and a two (2) car garage. There is vehicle provide by the Los Angeles County Children's Residential Fleet Inspected, to be operating in good condition. The vehicle is utilized to pick up supplies (i.e food, household cleaning supplies, and to transport clients to community outings, to seek medical attention in the event of and emergency. Staff has valid drivers license and covered by County of Los Angeles Risk Management Branch. Outdoor Area: The passageways and porches are unobstructed. The activity space is free of hazard materials and debris. LPA observed the utility shut-off valves for gas and water located in back yard side of the facility. LPA observed all windows, screens and drapes from the inside and outside of the facility were observed to be in good condition. There is mounted basketball court, and several trees and a black metal picnic table, a Barbecue Pit and a two (2) seater swing chair. LPA observed coverage trash cans in the kitchen, bathrooms and staff office. All posting requirements were met,(food menu posted on the refrigerator; regulations, emergency disaster plan is kept inside the office. LIC- Page 1 of In the dining area there is Grievance forms and a comment box mounted the wall. The Hot Water Heater is enclosed located inside the garage adjacent to washer and dryer unit. The central air conditioning unit is located in the hallway in between bedrooms 1 and 2. The two (2) car garage The door entrance to the garage from the kitchen is key locked for precautionary measures. There is a space for laundry units washer and dryer. The detergent is distributed according the youths individual load of clothing. The Licensee will ensure that the children are always monitored when they in doing there laundry. The garage is also utilized for extra storage, clothing, art supplies, food and (PPE) Personal Protection Equipment. There are two (2) freezers and a water bottle. Staff office: Is equipped with office furniture. There is a small refrigerator utilize to store medication that require to be refrigerated. All the clients prescribed medications; medication logs, files and medical devices are locked key entry. The cleaning supplies solutions, disinfectants are stored in the staff office. The sharp knives are also inaccessible in separate box in safe inside the key locked office. The First Aid kit met requirements, (age-appropriate, and scissors, tweezers, thermometer, and gauzes, antiseptic and First Aid Manual Guide). The facility has a working telephone and children can use the telephone unless restricted by court order; in addition, for the authorized representatives to make contact. LPA observed a hard wired enter connected combined smoke detector and carbon monoxide; tested to be operable. The Living Room is currently furnished with (4) large lounge chairs, one (1) television and a long table. Dining room/Kitchen: Observed to be clean and organized; The gas stove is operated with 5 burners; the oven is separate from stove. There is a double door refrigerator with upper freezer.The dining table has six (6) chairs. LPA observed ample linen in the linen closet locate in the hallway. LPA observed two (2) Fully Charged Fire Extinguishers located in the kitchen and in the staff office fully charged. There are three (3) Bedrooms: Each bedroom is equipped with two (2) twin size beds, clean linen, blankets, adequate drawer space (six (6)) one (1) walk in closet, sliding windows and drapes; observed to be in good condition. The personal rights are posted on the back of each bedroom door. LIC Page 2 of Bedroom # 1, BR #2 and BR #3 currently the bedrooms are not occupied. Bathrooms: There are two (2) bathrooms inspected and found to be clean. LPA ensured that all toilets flushed, and tested water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. Bathroom #1 is a full sized bathroom (sink, toilet shower and a tube) located in hallway. Bathroom #2 identified as staff bathroom; is a half bath with a sink toilet and a shower, located in the staff office. This is also a shower is not being utilized. The staff will accompany children local recreational activities. LPA observed that facility ensures that CDC Guidelines are implemented (i.e wash hands with alcohol based hand sanitizer, display colorful preventative hygiene posters, disinfect commonly used areas and items (remote controls, mouse's, playing, cards cell phones, practice "cough etiquette". The facility will operate within license conditions and limitations including capacity limitations. The facility personnel are instructed to report violations of personal rights. Licensee will ensure to report changes in the plan of operation affecting service to children. Children are accorded dignity in personal relationships with staff and others; and the Licensee will ensure to report client injuries requiring medical treatment. LPA reviewed the following during the inspection: Staff Records Review LPA reviewed four (4) staff records. Staff Interviews: LPA conducted a confidential interview with four (4) on duty staff. Clients Records Review: Currently there are no clients in placement. Client Interviews: Currently there were no clients in placement to interview. LPA reviewed the Personnel Report (LIC 500) and confirmed that staff ratio present for the six (6) clients in placement. LPA confirmed that all staff have required criminal record clearance. DOJ, FBI and Child Abuse Response; which meet qualification. LPA observed staff Annual Training that include the training transcripts for all staff and the First-Aid and CPR training were up to date. There were no deficiencies cited at this time. LPA concluded the Annual/Required Inspection on this day 12/17/2024. An exit interview was conducted, and a copy of this report will be provided via email to the facility House Manager Credell Jackson. LIC-809-C/ Page 3 of 3

met_with: House Manager Credell Jackson


facility_name: VALLEY OF THE MOON CHILDREN'S HOME

summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) David Hiett met with Administrator Sky Gray regarding a complaint investigation at the Temporary Shelter Care Facility. The purpose of the inspection was to deliver the findings for the above allegations. During the course of the investigation, LPA Hiett interviewed 5 youth and 5 staff, and reviewed documentation. Interviews with clients did not support any of the allegations. Interviews with staff revealed that staff were properly informed of mail protocol and proper procedures for determining discipline. This department has investigated the allegations, and although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the above allegations are true; therefore, the above allegations are unsubstantiated. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: David Hiett LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Sky Gray


raw_content:
Narrative:
This department has investigated the allegations, and although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the Staff sexually assaulted a minor; therefore, the above allegation is Unsubstantiated. Appeal Rights were provided and discussed, and no deficiencies were cited. An exit interview was conducted and a copy of the report was given to the facility.

Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Brian Bertoli made an unannounced complaint investigation visit at the facility and met with Supervising Residential Care Counselor Chris Bozzetto. The purpose of the inspection was to deliver findings regarding the above allegation. The investigation was conducted by Investigator Melissa Burgoon. During the course of the investigation Inv. Burgoon interviewed the youth C1 (see LIC 811 dated 5/10/22), C1's therapist and psychologist, 5 other youth currently or formerly at the facility, 4 facility staff, and reviewed records and reports. All persons interviewed, other than C1, stated they had no knowledge or indication that the allegation occurred. The 5 youth interviewed, other than C1, indicated they felt safe at the facility and did not have concerns about the staff. Investigator Burgoon was unable to determine if staff sexually assaulted a client. There is a lack of clear evidence to make a determination as to whether a regulatory violation did occur. (continued on LIC 9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: Brian Bertoli LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 21-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NEOTOMAS AVENUE, STE. FACILITY NAME: VALLEY OF THE MOON CHILDREN'S HOMEFACILITY NUMBER: VISIT DATE: 05/10/2022

met_with: Chris Bozzetto


raw_content:
Narrative:
This department has investigated the allegations, and although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that staff did not prevent client from engaging in CSEC activity; therefore, the above allegation is Unsubstantiated. Appeal Rights were provided and discussed, and no deficiencies were cited. An exit interview was conducted and a copy of the report was given to the facility.

Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) David Hiett made an unannounced complaint investigation visit at the facility and met with Program Manager.Sky Gray The purpose of the inspection was to deliver findings regarding the above allegation. Investigator Melissa Burgoon conducted the investigation. During the course of the investigation Inv. Burgoon conducted confidential interviews and reviewed relevant reports. Investigator Burgoon was unable to determine if staff did not prevent client from engaging in CSEC activity. There is a lack of clear evidence to make a determination as to whether a regulatory violation did occur. (continued on LIC 9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: David Hiett LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 21-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NEOTOMAS AVENUE, STE. FACILITY NAME: VALLEY OF THE MOON CHILDREN'S HOMEFACILITY NUMBER: VISIT DATE: 06/24/2022


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Cheyenne McCambridge met with Administrator Sky Gray regarding a complaint investigation at the Temporary Shelter Care Facility. The purpose of the inspection was to deliver the findings for the above allegations. During the course of the investigation, LPA McCambridge interviewed youth and staff, and reviewed documentation. Interviews with clients did not support any of the allegations. Interviews with staff revealed that staff were propeerly following protocal and procedures. LPA also toured the kitchen and found adequate food supply at the facility. This department has investigated the allegations, and although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the above allegations are true; therefore, the above allegations are unsubstantiated. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: Cheyenne McCambridge LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Cheyenne McCambridge met with Administrator Sky Gray regarding a complaint investigation at the Temporary Shelter Care Facility. The purpose of the inspection was to deliver the findings for the above allegations. During the course of the investigation, LPA McCambridge interviewed staff, and reviewed documentation. LPA was unable to interview clients involved due to refusal and unknown victim. There was also contradictory statements in the reporting party interview. Interviews with staff revealed that staff were not aware of any incident happening or being talked about. This department has investigated the allegations, and although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the above allegations are true; therefore, the above allegations are unsubstantiated. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Zaid Hakim LICENSING EVALUATOR NAME: Cheyenne McCambridge LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Brian Bertoli met with Section Manager Briana Downey regarding a complaint investigation at theTemporary Shelter Care Facility. The purpose of the inspection was to deliver the findings for the above allegation. During the course of the investigation, LPA Bertoli inspected the facility, interviewed youth, staff, and youth's representatives, and reviewed documentation. LPA confirmed through interviews with youth that there were incidents of one staff, who is no longer at the facility, who would touch the youth inappropriately. This was also supported by interviews with staff who indicated that the reports from the youth were consistent and they felt it was valid and that the youth involved were not prone to fabrication of events. Based on the information obtained, there is a preponderance of the evidence to prove that staff touched the minor inappropriately. Therefore, the above allegation is substantiated. Title 22 deficiencies were cited and Appeal Rights were provided and discussed with the facility. An exit interview was conducted and a copy of the report was left with the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Brian Bertoli LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 21-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SANTA ROSA RO, NEOTOMAS AVENUE, STE. FACILITY NAME: VALLEY OF THE MOON CHILDREN'S HOMEFACILITY NUMBER: 496890002

met_with: Briana Downey

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
LPA Hood reviewed the program statement for the facility. The program statement requires that staff have sight of the youth every thirty minutes while they are in their rooms for safety reasons. Based on confidential interviews, exceptions have been made when warranted. Based on five of the six interviews, youth had received medical attention consistently within the facility. Based on record review and interview, there is a medical professional on site. LPA was not able to interview the youth that was involved in this allegation. Based on IB investigation, record review, and confidential interviews, the following allegations are found unsubstantiated: minor in care used an illegal substance due to lack of staff supervision, staff are not adequately supervising minors in care, staff do not provide trauma informed services to minors in care, and staff did not seek medical attention for minor in a timely manner. LPA Hood conducted an exit interview with Sky Gray, Director, at 1:11PM whose signature confirms the receipt of this document.

Investigation Findings:
13On 6/1/2023 at 1:02PM, Licensing Program Analyst (LPA) Selena Hood conducted an unannounced visit to the licensed facility. The purpose of the visit was to deliver the findings for the listed allegations. LPA met with Sky Gray, Director. Investigation Branch (IB) Investigator Jorge Martinez completed the 10-Day visit to the facility on 3/24/2023. Based on thirteen confidential interviews and record review, IB found the allegation that "minor in care used an illegal substance due to lack of staff supervision" to be unsubstantiated. During the course of the investigation, Licensing Program Analyst (LPA) Selena Hood conducted six confidential interviews. LPA Hood reviewed pertinent incident reports, staff schedule, program statement, pertinent client files, and the IB report. LPA Hood reviewed the staff schedule, based on record review the staffing was consistently within ratio. Based on five of the six interviews there were not concerns with staffing supervision. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Helga Wong LICENSING EVALUATOR NAME: Selena Hood LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 21-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: VALLEY OF THE MOON CHILDREN'S HOMEFACILITY NUMBER: VISIT DATE: 06/01/2023

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


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Brian Bertoli met with Administrator Sky Gray regarding a complaint investigation at the Temporary Shelter Care Facility. The purpose of the inspection was to deliver the findings for the above allegation. The investigation was conducted by Investigations Bureau Investigator Blake Williams. During the course of the investigation Investigator Williams spoke with the victim, who indicated that he did not wish to pursue it at this time, and they did not provide any further information. Therefore Investigator Williams was not able to complete the investigation. This department has investigated the allegations, and although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the above allegations are true; therefore, the above allegations are Unsubstantiated. An exit interview was conducted and no deficiencies were cited. A copy of this report was given to the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Brian Bertoli LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


facility_name: WAYFINDER FAMILY SERVICES - TSCF

raw_content:
Investigation Findings:
13On June 2, 2021, at 11: AM, Licensing Program Analyst (LPA) Charmetha White contacted the above location via telephone for the purpose of concluding the investigation and deliver findings on the above allegation. LPA spoke with the Program Director, Kristal Audoma and discussed the findings. During the course of this investigation, LPA interviewed pertinent parties and reviewed records. Interviews and records did not produce corroborating evidence to support the allegation. Staff denied there being a lack of supervision and stated staff are always present. Staff stated verbal redirect was used to discourage the behavior, however both clients continued the behavior and refused to stop. Additionally, Staff stated Client #1 met with the therapist continuously to address behaviors. LPA was unable to obtain statements from Client #1 and Client #2 as clients were no longer in placement. Although there was inappropriate contact between the clients in the facility. The Staff made attempts to intervene and deter the clients. Based on information obtained, the allegation is found to be unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violations did or did not occur. No deficiencies cited. Exit interview completed and a copy of this report was emailed to Program Director, Kristal Audoma. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Charmetha White LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

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

met_with: Program Director - Kristal Audoma


raw_content:
Investigation Findings:
13On November 19, at 11: AM, Licensing Program Analyst (LPA) Charmetha White arrived at Wayfinder TSCF for the purpose of concluding the investigation and deliver findings on the above allegations. LPA met with Director, Kaela Stambor. During the course of this investigation, LPA interviewed pertinent parties and reviewed records. Staff denied allegations and stated that none of the staff would ever say or do anything inappropriate to a child in care. Staff stated that sexual interactions between staff and clients is prohibited and is grounds for immediate termination. Additionally, Client interviews did not produce corroborating evidence to support the allegations and there were no witnesses to either allegation. Based on information obtained, the allegations are found to be Unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violations did or did not occur. No deficiencies cited. Exit interview completed and a copy of this report was left with the Director, Kaela Stambor. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Charmetha White LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

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

met_with: Director - Kaela Stambor


raw_content:
Narrative:
The investigation consisting of confidential interviews, review of police report and related reports from the Department of Children and Family Services revealed a lack of evidence to support alleged neglect/lack of supervision. C1 declined to give Investigator a statement during the investigation process. Information obtained from witness statements did not produce information to corroborate neglect/lack of supervision leading to sexual and/or physical abuse towards C1 by another youth resident. The Department has investigated the complaint and found that the allegation is Unsubstantiated at this time; although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove neglect/lack of supervision contributed to the alleged. There were no deficiencies cited at this time. Appeal Rights issued and discussed.

Investigation Findings:
13On May 6, 2022 at 12: PM, Licensing Program Analyst Regina Martin conducted a subsequent complaint inspection to conclude and deliver findings concerning the allegation as mentioned above. LPA Martin met with Irene Manzanares, Assistant Director of Campus Safety and Program Support and advised the Complaint Investigation, investigated by Community Care Licensing Division (CCLD) Investigator Lorraine Patterson has been completed. Investigation details are discussed. On October 28, 2021, CCLD received a complaint referral alleging neglect/lack of supervision as Client #1 (C1) was reportedly sexually and physically assaulted by another resident while at the facility in June 2021 and in August 2021. C1 was reportedly observed at some point with a visible injury to the eye. It was reported that the sexual assault was not reported to staff and that the alleged perpetrator was transferred to a different facility. (Continued on page LIC9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Regina Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: WAYFINDER FAMILY SERVICES - TSCFFACILITY NUMBER: VISIT DATE: 05/06/2022

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

visit_type: Complaint Investigation


raw_content:
Investigation Findings:
13On May 31, 2022 at 10am Licensing Program Analyst (LPA) Donald Martin conducted a follow up complaint inspection and spoke with Facility . The purpose of this inspection was to deliver findings for the above complaint allegation. During the course of investigation the allegation for facility staff is insufficiently staffed to meet the needs of the minors, interviews were conducted. The interview did not produce corroborating evidence to support said allegation. Interviews revealed inconsistent statements and no witnesses to suggest allegation occurred. There was no evidence of the facility being insufficiently staffed to meet the needs of the minors. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred; therefore, the above allegation is Unsubstantiated. There are no deficiencies being cited at this time. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

met_with: Kaela Stambor-Director


raw_content:
Investigation Findings:
13On 06/23/2022 at 9:30am, Licensing Program Analyst (LPA) Bernice Karnsrithong arrived at the facility for the purpose of delivering findings for the above complaint. Health and safety risk assessment were conducted upon arrival. LPA Karnsrithong met Kaela Stambor, Director who granted access to the facility.During the investigation of the allegations, minors are smoking marijuana while in care, staff do not provide adequate supervision to the minors while in care, and staff are not properly trained; LPA Karnsrithong conducted confidential interviews and reviewed documentary evidences. Statements were inconsistent and did not produce corroborating evidence that minors are smoking marijuana while in care, staff are not providing adequate supervision to the minors while in care and staff are not properly trained. There was no witness to corroborate the allegations and documentary evidences suggest that facility has an extensive policy on substance abuse and contraband searches and facility staff are receiving regular training. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. This complaint investigation is deemed unsubstantiated.There are no deficiencies cited at this time. Exit interview was conducted with Kaela Stambor and a copy of this report will be provided. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Bernice Karnsrithong 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: Kaela Stambor, Director


raw_content:
Narrative:
Due to lack of evidence obtained during the investigation, LPA determines that the allegations are unsubstantiated at this time meaning, although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. There were no deficiencies cited at this time. Exit interview conducted with Kaela Stambor, Director for TSC. A copy of this report will be provided to the facility.

Investigation Findings:
13On 07/13/2022 at 1:30pm Licensing Program Analyst (LPA) Bernice Karnsrithong arrived at the facility for the purpose of delivering findings for the above complaint investigation. Health and safety risk assessment were conducted upon arriving at the facility. During the visit, LPA Karnsrithong met with Kaela Stambor, Director of Temporary Shelter Care (TSC) who granted access to the facility. During the investigation of the following allegations: Residents are not adequately supervised, Young children have eloped from the facility, Staff are not trained to work with the residents, and Needs of the residents are not being met; LPA Karnsrithong conducted confidential interviews and reviewed documentary evidences. Statements were inconsistent and did not produce corroborating evidence to support that staff do not provide adequate supervision to clients, staff not being able to provide the needs of clients, and staff are not trained to work with residents. Although there were incidents of clients eloping or engaging in runaway activities, there were no corroborating evidence that suggest that staff are not complying with appropriate emergency intervention and appropriate runaway procedures. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Bernice Karnsrithong LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: WAYFINDER FAMILY SERVICES - TSCFFACILITY NUMBER: VISIT DATE: 07/13/2022

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

met_with: Kaela Stambor


raw_content:
Investigation Findings:
13On 08/04/2022 at 9am, Licensing Program Analyst (LPA) Bernice Karnsrithong arrived at the facility for the purpose of delivering findings for a complaint investigation. Health and safety risk assessment were conducted upon arriving at the facility. LPA Karnsrithong met with Kaela Stambor, Director who granted access to the facility. During the investigation of the allegations, Staff member had sexual relations with minors in care and Staff member allowed group home children to drive the staff member's car; LPA Karnsrithong conducted confidential interviews and reviewed documentary evidences. Statements and documentary evidences did not produce corroborating evidence to support that the allegations; staff member had sexual relations with minors while in care or allowed group home children to drive a staff member's car. There were no witnesses to corroborate that such incidents have occurred. Internal investigation from the facility also determines that there was not enough evidence to substantiate these allegations. Therefore, LPA Karnsrithong determines that the allegations are unsubstantiated at this time meaning, although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. There are no deficiencies cited at this time and a copy of this report will be provided. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Bernice Karnsrithong LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Kaela Stambor, Director for TSC


raw_content:
Investigation Findings:
13On 08/04/2022 at 9am, Licensing Program Analyst (LPA) Bernice Karnsrithong arrived at the facility for the purpose of delivering findings for a complaint investigation. Health and safety risk assessment were conducted upon arriving at the facility. LPA Karnsrithong met with Kaela Stambor, Director who granted access to the facility.During the investigation of the allegations, lack of supervision between minors while in care and staff did not properly report an incident regarding a minor while in care; LPA Karnsrithong conducted confidential interviews and reviewed documentary evidences. Statements and documentary evidences did not produce corroborating evidence that support lack of supervision between minors while in care and staff did not properly report incident regarding minors. Statements and documentary evidence suggest that the facility has extensive supervision and reporting procedures and policies that staff are trained on and is implemented to supervise while minors are in care. Due to lack of evidence obtained during the investigation, LPA determines that the allegations are unsubstantiated at this time meaning, although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. There are no deficiencies cited and a copy of this report will be provided to the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Bernice Karnsrithong 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


facility_name: 3R'S GROUP HOME, INC-THP+FC PROGRAM

raw_content:
Investigation Findings:
13On 11/22/23, Licensing Program Analyst (LPA) Lisa Slusher conducted an unannounced complaint investigation for the above facility. Met by program Director Fatimah Rodriguez. Confidential Interviews conducted and information and documents obtained. Based on confidential interviews conducted and information obtained, there are conflicts. Based on the above, the complaint is Unsubstantiated. There are no deficiencies to be cited on this date. A copy of this report is given on this date to the Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lisa Slusher LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

met_with: Fatimah Rodriguez


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst Lisa Slusher and LPA Briana Placencia travelled to the 3R's THP + NMD office in Fresno CA. LPA was met by Administrator Fatimah Rodrigez , for the purpose of a scheduled pre-licensing inspection for a change of location for a THP + NMD. A general overview of their program and a tour of the facility was provided. This facility has a reception area, waiting area, and office space for staff. Observed fixtures and furniture, equipment and supplies necessary for this operation. Also observed locked cabinets for client and staff files in order to ensure confidentiality. Discussed daily ongoing functions including incident reports. There is ample confidential space for meeting with clients on an as needed basis. The agency employs one administrator, one social worker supervisor, two social workers and four case managers. All files are to be moved from location currently licensed at N. Van Ness Ave., Fresno. All facility staff fingerprints will transfer to the license number listed on this report following licensure. The agency intends to submit an application for a capacity change. The agency will submit a new LIC 200, board resolution and processing fee. The above licensee meets the requirements to be licensed as a THP+NMD in Fresno County county, to be extended to other counties within a two hour driving distance with program statement update. On a quarterly basis, facility is to submit a roster of THP+NMD clients that includes client names, dates of birth, county worker and current address of placement.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, LPA Lisa Slusher conducts a post licensing visit at the above licensed facility. Met by Administrator Fatimah Rodriguez. Facility physical plant inspected. Agency has adequate space for Social Work activities and confidential meeting space with youth. Files are appropriately secured. Discussed current operations, plans for the facility and incident reporting. Received updated LIC 500. Recejved roster of clients, certified THP+FC units. Discussed agency activities to secure housing units. Reviewed client and personnel files. Discussed updates and improvements to needs and services plans. No deficiencies noted on this date.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/01/2021, an unannounced annual inspection is conducted by Licensing Program Analyst (LPA) T. Met at the THPP office by Program Manager Fatimah Rodriguez . Currently the program is staffed by the Administrator, a Program Manager, a Supervising Social worker, two Case Managers and 6 independent Living Support Staff. At 10:00AM, participant files and staffing files reviewed. All staff meet appropriate regulatory requirements. Licensee provided updated client roster and personnel report. There are no deficiencies to be cited on this date. A copy of this report is left with the Program Manager A Technical Violation is issued on this date for Reporting Requirements. Discussed updated staffing for the facility and potential changes. .


summary: Facility Evaluation

raw_content:
Narrative:
On this date a case management inspection is conducted by LPA (Licensing Program Analyst) Lisa Slusher. Met at the office by Program Manager Fatimah Rodriguez. Discussed Emancipation accounts for youth and the distribution of funds to youth who exit the program. Agency will ensure that process is consistent with what is noted in the program statement or will submit an update for the program statement Agency to submit an updated LIC 400 and ensure that the department has the original bond. Discussed potential capacity increase. Facility to submit the following: 1. LIC 200 2. Board Resolution approving increase 3. LIC 500 including staff to be added in accordance with census and regulatory ratios 4. $25 processing fee


summary: Facility Evaluation

raw_content:
Narrative:
On this date, a case management inspection is conducted by LPA (Licensing Program Analyst) LIsa Slusher. Met at the facility by Fatimah Rodriguez. Discussed incident report dated 10/31/23. LPA conducted review of file for S1 and C1 (See LIC 811 dated 11/6/23). Further investigation into this incident will be conducted.


facility_name: 3R'S THP+FC

summary: Facility Evaluation

raw_content:
Narrative:
On this date an unannounced annual inspection is conducted at the THP+FC office with Program Manager Fatimah Rodriguez. LPA inspected both the participant's files and staff files. Facility provided the following forms upon inspection: LIC LIC LIC 610C Roster of Participants There were no deficiencies cited during this inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On this date a case management inspection is completed by LPA Lisa Slusher. Facility is in the process of changing the administrator and appropriate documentation will be submitted within 10 days of that change. LPA to follow up on capacity increase dates.


summary: Facility Evaluation

raw_content:
Narrative:
On this date 2/23/22 at 1:30 pm Licensing Program Analyst (LPA) Lisa Slusher travelled to the facility to conduct an annual inspection. Prior to this inspection a pre-inspection Covid screening was conducted. Met with Administrator Fatimah Rodriguez.. A physical plant inspection was completed and included the following checks: client and staff files are kept in locked filing cabinets, and are printouts from an electronic filing system. Facility has adequate confidential meeting space and space for Social Workers to complete job duties. A review of their staff files on this date indicate that all facility staff have received child abuse index clearances and fingerprint clearances. Agency staff meet requirements of respective job descriptions. Agency Employs one Administrator, One Social Worker Supervisor/Social Worker, one Case Manager. Agency is in the process of onboarding an additional Case Manager. Employee and THPP Participant files reviewed. THPP Participant files were transferred from the Licensee's Tracy office. An exit interview was conducted with the Administrator.


facility_name: 3RS THP+FC

raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA), Lidia Tinoco conducted an unannounced visit to the 3R's THP+FC in order to deliver the findings of the above allegations and met Housing Supervisor, Kesha Ingram. On June 19, 2024, the above allegations were referred to Community Care Licensing for investigation. The investigation included an inspection of the Facility, confidential interviews, and review of records. Based on the investigation conducted the department found that there was conflicting information regarding these issues. Although the allegations may have happened of are valid, there is not a preponderance of evidence to prove the allegations occurred. Therefore, the allegations are Unsubstantiated at this time. A copy of this report was provided at the conclusion of the inspection along with appeal rights. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lourey Bartolome LICENSING EVALUATOR NAME: Lidia Tinoco LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Kesha Ingram


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst Lisa Slusher travelled to the 3R's THP + NMD office in Fresno CA. LPA was met by Administrator Fatimah Rodrigez , for the purpose of a scheduled pre-licensing inspection for a change of location for a THP + NMD. A general overview of their program and a tour of the facility was provided. This facility has a reception area, waiting area, and office space for staff. Observed fixtures and furniture, equipment and supplies necessary for this operation. Also observed locked cabinets for client and staff files in order to ensure confidentiality. Discussed daily ongoing functions including incident reports. There is ample confidential space for meeting with clients on an as needed basis. The agency employs one administrator, one social worker supervisor, two social workers three case managers and ILSS workers. All files are to be moved from location currently licensed at W. Shields Ave. All facility staff fingerprints will transfer to the license number listed on this report following licensure. The above licensee meets the requirements to be licensed as a THP+NMD in Fresno County county, with the ability to place participants within a two hour radius. On a quarterly basis, facility is to submit a roster of THP+NMD clients that includes client names, dates of birth, county worker and current address of placement.


summary: Facility Evaluation

raw_content:
Narrative:
On this date, an unannounced case management inspection is conducted by LPA (Licensing Program Analyst) Lisa Slusher. Met with Shatari Sykes. LPA spoke with Administrator Fatimah Rodriguez by phone. The purpose of this inspection is to follow up on an incident report received 3/25/24 which occurred on 3/11/24. A technical violation is issued on this date for reporting requirements for failure to report the incident within prescribed time frames. Additionally, LPA discussed provider issues with Guardian and completed an employee transfer while at the facility.

met_with: Shatari Sykes


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analysts (LPAs), Lidia Tinoco and Sonia Sanchez arrived at 3R's THP+ FC for the purpose of conducting an unannounced Post Licensing inspection. LPA met with Program Administrator, Shatari Sykes and Director, Fatimah Rodriguez and inspected the facility, inside and out. The facility has a written emergency disaster plan. A fire extinguisher is properly charged. Facility has cameras in common areas of the facility. The facility employs Administrator, Social Worker Supervisor, Social Worker, Case Managers, Administrative Assistants and Office Manager. Five records of personnel/staff members were reviewed to ensure staff meet regulatory requirements. Personnel Files are maintained on-site. The assigned Licensing Program Analyst will work with the facility regarding fingerprint clearances and Guardian. Five records of clients were reviewed. Staff interview was conducted. Two type B deficiencies are being cited, see LIC809D. Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were provided at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst (LPA), Lidia Tinoco arrived at the 3R's and met with Administrator, Fatimah Rodriguez. At the time of the visit Administrator provided LPA Tinoco emails that were sent out on July 1, 2024 that were not delivered to LPA due to an error in the email. On this date, Administrator provided LPA the POC documents requested. The POC for deficiencies issued on 6/24/24 were cleared on today's date. The POC Clearance Letter was provided to Administrator. No deficiencies were cited on this date. A copy of this report was provided at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst Lisa Slusher arrived at 3R's THP+ FC for the purpose of conducting an unannounced Annual inspection. LPA met with staff person Nuryah Williams and spoke with Administrator Fatimah Rodriguez by telephone who arrived a short time later, and inspected the facility, inside and out. The facility has a written emergency disaster plan. A fire extinguisher is properly charged. Facility has cameras in common areas of the facility. Certificates of compliance were observed for all remote/scattered sites where participants are placed. The facility employs Administrator, Social Worker Supervisor, Social Worker, Case Managers, Office Manager and Independent Living Support staff. Six records of personnel/staff members were reviewed to ensure staff meet regulatory requirements. Personnel Files are maintained on-site. All staff are appropriately fingerprint cleared and associated. Six Records of clients were reviewed. Staff interviews were conducted. No deficiencies noted in areas observed A copy of this report and appeal rights were provided at the conclusion of the inspection.