summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On October 21, 2025, Licensing Program Analyst (LPA) Charmaine Linley, met with Applicant, Markiesha Brown, for Component II Orientation for a Group Home. The following questions were discussed and answered: Ms. Brown stated they have previously worked in STRTP facilities and will provide letters of experience for the Administrator qualifications. Ms. Brown stated they received their Administrator Certificate earlier this year and LPA reviewed the qualifications for Ms. Brown to qualify as an Administrator. If Ms. Brown does not meet the qualifications, Ms. Brown can submit an Exception letter to LPA for Administrator qualifications. LPA asked if Ms. Brown or Remia will be living at the facility and Ms. Brown stated they will not be living at the facility and Remia will not be living at the facility. LPA reviewed the LIC 500 and to indicate positions on the LIC 500 so as to be hired to ensure there is adequate coverage for the facility. LPA reviewed some of the budget costs were lower than normal and Ms. Brown will update the monthly budget or provide a statement with an explanation of the costs. LPA provided a copy of the LIC 184, LIC 281, and CRP PIN 24-09, to assist with the revisions needed to the application via email. The revisions are due by November 4, 2025, by 5:00 pm. Overall Notes: Section B documents as noted in the LIC 281 were not provided. Please provide all Section B documents that are identified either at the top of the page or through a cover sheet. *** Section A Documents: A1. Application (LIC 200):  #8: Alternative Public Phone Number needs to be completed.  #10: needs to be completed. A2. Applicant Information (LIC 215):  Education: Please explain if the High School and College are the same schools and completion dates.  References: Addresses need to be completed.  Work Experience: CCRC address needs to be completed. A3. Applicant Information (LIC 308):  Date needs to be filled out.  Facility number needs to be filled out.  Remia Williams needs to be added in Guardian and associated to the facility. A4. Administrative Organization (LIC 309):  Provide the LLC Operating Agreement.  Please explain why Remia Williams is listed on the Secretary of State website as a member and they are not listed on the LIC 309. A7. Monthly Operating Statement (LIC 401):  Provide an explanation of the following areas:  # Transportation is estimated to be very low.  # Salaries and wages seem to be low.  # Insurance - the lease states that the LLC will provide liability insurance, this needs to be indicated on this form and any other types of insurance.  #28 why property taxes are not indicated.  #30 electricity seems to be low.  # 33 and #34 why are there no expenses indicated for repair and maintenance. *** A8.b Balance Sheet (LIC 403):  Remove crossed out sections. A8.c Balance Sheet Supplemental Schedule (LIC 403a):  Provide a copy of the ownership documentation for Property #1 with the purchase price and current value. A10. Personnel Report (LIC 500):  Facility Number needs to be filled out.  Name of the person that prepared form needs to be filled out.  We cannot approve individuals to be working 7 days per week and not have any days off. The facility needs to follow California labor laws. There needs to be enough coverage for all the hours you can put to be hired, however, there is not enough coverage at this time to approve.  Social Worker: days and times needs to be filled out.  Administrator needs to be fully spelled out.  Dates employed needs to be filled out. A11. Personnel Record (LIC 501):  Cross out sections need to be removed.  Information needs to be written legibly or typed.  Facility Number at the top right of the form needs to be completed.  References: Addresses needs to be completed. Remia Williams:  Date needs to be filled out.  Remove crossed out sections.  Information needs to be written legibly or typed.  References: Addresses needs to be completed. LaKechia Donald:  Previous Employment: Addresses needs to be completed. *** A12. Health Screening Report - Facility Personnel (LIC 503):  Markeisha: The Health Screening Report and TB Test are over one year old and cannot be accepted. Please provide a new Health Screening Report and TB test that includes the Duty Statement.  The Physician needs to write out what is "WNL."  Please do not use wite-outs on the forms.  LaKechia: Need original signed Health Screening Report, we cannot accept a photocopy.  The Health Screening Report and TB Test are over one year old and cannot be accepted. Please provide a new Health Screening Report and TB test that includes the Duty Statement.  Types of persons needs to be filled out. A14. Emergency Disaster Plan (LIC 610C, LIC 610D,LIC 610E):  Remove crossed out section.  Information needs to be written legibly or typed.  Administrator needs to be fully spelled out.  Provide letters of permission from both relocation sites with the printed and signed name of the authorized agent. A15. Facility Sketch (LIC 999):  Include the garbage storage areas on this form.  Will the facility have a Ring doorbell or any video cameras? Section B Documents were not provided. B1. Partnership Agreement/Articles of Incorporation/Articles of Organization:  This section was not provided.  Provide a copy of the LLC Operating Agreement in this section. B2. Verification of Administrator Qualifications and Certification:  This section was not provided. ***  Have completed high school, or equivalent, plus at least three years administrative experience or supervisory experience over social work, child care, and/or support staff providing direct services to children in an agency or in a community care facility with a licensed capacity of seven or more.  Written references are to be obtained and submitted to the licensing agency. References are used solely to determine that the experience requirement is met (i.e., the person worked there, in the particular capacity, the specific duties performed, for a specified period of time). The written letter must be submitted by the employer who can speak about the information listed above.  Provide the name and residence and mailing addresses of the facility administrator, a description of the administrator's background and qualifications. B3. Verification of Social Worker Qualifications:  This section was not provided.  This section is missing the documents listed below:  LIC 215: Applicant Information  LIC 501: Personnel Record  LIC 503: Health Screening Report  Verification of education and experience, copy of degree and transcripts, and resume  Photo ID  Copy of First Aid Certificate B4. Job Description - each position:  This section was not provided.  Provide a job description for all positions which corresponds with the LIC 500 to include:  Duties and responsibilities;  Minimum qualifications that correspond to licensing requirements. This is to include any special licenses or certificates or special skills needed to perform the job;  Lines of supervision. B5. Personnel Policies:  This section was not provided. ***  Provide the work hours/shift for documentation of positions to provide coverage with competent staff, to correspond with staff positions and works days and hours listed on all personnel reports.  Describe the abuse reporting procedures:  Describe the types of abuse the facility will report and how it is documented the employees are informed of their responsibilities to report to the licensing agency as well to the policy and child protective services.  Describe how the facility will provide a report to the licensing agency within the agency's next working day during its normal business hours.  Describe how a Supervisor or Administrator does not impede or inhibit the reporting of duties of mandated reporters.  Describe how the facility shall not sanction, punish, or discipline any person for making a report.  Describe how the facility shall not direct an employee or independent contractor to allow their supervisor to file or process a mandated report on their behalf or require an employee to disclose their identity to the employer.  Hiring Practices: Describe the screening of employees for necessary education and experience and informing employees that conditions of their employment include fingerprint clearance, statement of prior criminal convictions, TB clearance, physical examination/health questionnaire, child abuse index check. B6. In Service Training for Staff:  This section was not provided.  Provide a descriptions of the New Employee training and who will be conducting their training along with their qualifications.  Provide the topics to be covered in the ongoing training, along with who will be conducting the training, along with their qualifications.  Include the Administrator continuing education units, how often the training will be documented and include topics specified in the LIC 281. B7. Facility Program Description:  This section was not provided.  Provide a statement of the purpose, goals, and program methods.  Provide the days and hours of operation. ***  Provide a daily schedule of activities to be provided by the facility that needs to state who plans, conducts, and assists clients in participating in these activities.  Provide a one month schedule of planned social, education, and recreational activities that needs to state who plans, conducts, and assists clients in participating in these activities.  Provide a description of basic services provided by the facility.  Describe any optional services listed in the Admission Agreement.  Describe how the facility is going to handle medical emergencies if a client becomes ill or injured  Describe the procedure for handing and assisting clients with self-administered medications.  Describe how the motor vehicles used to transport clients shall be maintained in a safe operating condition.  Describe how the licensee and their staff are prohibited from smoking a tobacco product, or permitting any person from smoking a tobacco product in a motor vehicle that is regularly used to transport children, regardless of when the children are present. This prohibition applies when the motor vehicle is moving or at rest.  Provide a description of list of community resources and consultants to be used by the facility.  Provide the complaint/grievance procedures in this section including, how to submit a grievance/complaint, who responds, the timeframe, how the outcome is documented, where is the procedures documented. B8. Rules of Discipline/Personal Rights:  This section was not provided.  Provide a statement that discipline does not include a violation of personal rights.  Describe the types of discipline that will be used and under what conditions each type will be used. The discipline policies shall also address the following, when appropriate: types of discipline not permitted.  Provide the grounds for planned discharges/unplanned discharges from placement.  Provide a clear statement that there will be no corporal or unusual punishment used.  Describe how the child will sign the personal rights form at intake and each time a new right has been added.  Provide a copy of the discipline policy and describe how the child and Authorized Representative will sign the form. *** B9. Admission Policies:  This section was not provided.  Describe the persons accepted for care, including age range and compatibility determination process, when necessary.  Describe the criteria for assessing appropriateness of placement given an individual client's needs (i.e., interviews, procedures for obtaining and developing the necessary paperwork, etc.)  Describe the needs and services plan.  Provide a statement that clients/residents will be informed of their rights and that client's/resident's rights will not be violated).  Describe the pre-admission appraisal plan in this section.  Describe how the facility will obtain emergency information.  Describe the sign-in and sign-out procedures.  Describe the physical examination requirements/immunization requirements/TB test in this section. B10. Sample Menu:  This section was not provided. The sample menu will include:  Planned meals and snacks for one week, foods used should be from the four basic food groups.  Portion sizes.  Times meals served. B11. Control of Property:  This section was not provided.  Name and address of the owner must be provided.  Proof of ownership must be provided if the applicant is the owner of the property. The licensing agency can verify this by a Property Tax bill, Deed or other related document. The documents provided must contain the facility street address within the document or its' attachments. B12. Bacteriological Analysis of Private Water Supply (When Water for Human Consumption is from a Private Source):  This section was not provided. *** B15. Neighborhood Complaint Policy:  This section was not provided.  Describe the procedure for immediate responses to incidents and complaints.  Include the time when the Licensee or Administrator will be available to meet with neighborhood residents. B16. First Aid Card:  This section was not provided.  Provide a CPR/1st Aid card for the Applicant. B18. Group Home Program Statement:  This section was not provided.  Use the LIC 9106. Program Statement: Sec # Purpose, Methods and Goals {Ref: CCR: 80022(b)(1); MPP11-402.356(a)}.  The ages are not the same age as listed on the LIC 200, please make sure all ages in all sections are the same as listed on the LIC 200.  Describe how the clients will be assessed.  Describe what type of treatment will be provided.  Describe how the results or outcomes will be measured and how often Sec # Planned Activities/Use of Community Resources {Ref: CCR 80022(b)(13),84065(e), 84079}.  Describe the plan for individual child activities and group interaction activities.  Describe which children are involved in the activities.  Provide a list of community resources used by the program that is specific to your area, this area is too vague.  Describe the program's planned educational activities and services. Include: *** • Special Education; • Use of public and/or private schools; • On grounds school; and • Tutoring, if applicable  Provide a sample daily activity schedule for one week, including weekends and holidays. The schedule must include social, recreational, and education activities. Sec. # Special Services/Programs Offered  Describe if the program will provide vocational training, if so describe: • The skills taught; • Goals of the training program; • Hands-on experience received; • Materials provided; • Number of hours per day/days per week training is provided; and • How training is funded. Sec. # Medical and Dental. (Ref: CCR 80075 (a) (1)-(2).  Describe the procedure for handling and assisting children with self-administered medication.  Describe procedures used to identify and handle medical, dental and psychiatric emergencies, outside of calling 911.  Identify staff position(s) responsible for dispensing and destroying medications.  Describe how the facility will obtain a copy of the current court order, or written authorization of the child's parent or guardian, for each psychotropic medication.  Describe the use of Psychotropic Medication Administration Records (PMAR LIC 622B). A separate log for each psychotropic medication prescribed to the child.  Provide a statement that medication errors will need to be reported and documented to CCL, according to the timeframes for reporting requirements.  Provide a statement that any medication refusal by a client is considered a "Special Incident" and a report will be sent to Community Care Licensing. *** Sec. # Transportation (Ref: CCR 80022 (b)(10).  Describe if the staff will be using their own vehicles for transporting the children.  Specify how the program will ensure that vehicles used to transport children are maintained in safe operating condition.  Specify how the program will ensure that vehicle registration and insurance will be maintained.  Specify how the program will ensure that only appropriately licensed program staff and volunteers will transport children. Sec. # Admission/Intake (Ref: CCR 80022(b)(2) 84068.1 84068.2).  Describe the timeframe for responding to referring agencies regarding acceptances or rejection of referral.  Describe the staff position responsible for intake.  Describe the procedures for accepting emergency placements on a time-limited and/or trial basis. Sec. # Needs and Services Plan/Assessment {Ref:CCR 84022(b)(2)}.  Describe who writes the Needs and Services Plan, "qualified staff," is too vague.  Describe the procedures for implementing and modifying the Needs and Services Plan.  Describe the policy regarding participating of the child and their Authorized Representative in developing, updating and modifying the Needs and Services Plan. Sec # Discharge/Removal (Ref: CCR 84068.2, 84068,4).  Provide a copy of the discharge/removal form that the child and Authorized Representative will sign in this section. Sec. # Visitation Rules and Policies (Ref: CCR 80068 (b)(8) 80068,2 (b)(6), 84072).  Describe when and under what circumstances children can be visited at the facility by friends and others.  Include that any supervised visits needs to be documented and signed off in the Needs and Services Plan.  Describe when and under what circumstances the child is permitted to have home visits with relatives.  Describe when and under what circumstances the child is permitted to have overnight visits with relatives, family members, and friends. *** Sec. # House Rules.  Describe the policy of allowing children to be unsupervised away from the facility, including issuing passes to children.  Provide more information on what contraband is considered to be removed.  For belongings to be removed (phones, tablets, etc.,) the reason why must be documented and included in the Needs and Services Plan with signatures from the child and Authorized Representative.  Provide a copy of the house rules the child will sign in this section.  Specify other house rules to include: • Curfew hours on weekends and holidays; • Smoking; • Dating other children in placement; • Completing homework; • Dress Code; • Laundry Sec. # Discipline Policies [Reference: CCR 80072(a)(3), (7) - (8), 84072, 84072.1]  Describe the conditions under which each type of discipline will not be used.  Include a statement that discipline does not violate personal rights.  Describe the provisions for contact with parents and/or placement representatives (conferences).  Include the discipline policy the child and Authorized Representative will sign in this section. Sec .# Emergency Intervention Plan (Ref: CCR 84800(d), 84801, 84802, 84802.1,84803, 84804 and 84808.  Provide the resume and qualification of the individual who designed the Emergency Intervention Plan. 1.Individuals vendored as a behavior management consultant prior to, or as of, December 31, 2006, that have not previously completed twelve semester units in applied behavior analysis, shall have until December 31, 2008 to complete twelve semester units in applied behavior analysis and possess a license and experience as specified in 3. through 7. below. 2.Individuals vendored as a behavior management consultant on, or after, January 1, 2007, shall, prior to *** being vendored, have completed twelve a\semester units in applied behavior analysis and possess a license and experience as specified in 3. through 7. below. 3.Possesses a valid license as a psychologist from the Medical Board of California or Psychology Examining Board; or 4.Is a Licensed Clinical Social Worker pursuant to Business and Professions Code, Sections 4996 through 4998.7; or 5.Is a Licensed Marriage and Family Therapist pursuant to Business and Professions Code, Sections 4980 through 4984.7; or 6.Is any other licensed professional whose California licensure permits the design and/or implementation of behavior modification intervention services. 7. Have two years experience designing and implementing behavior modification intervention services.  Provide a list of the blocking techniques in this section.  Provide the Admission Agreement in this section that must include a written statement regarding the type(s) of emergency interventions that will be used.  Describe how a child does not remain in a manual restraint for more than 15 consecutive minutes, unless written approval to continue the restraint after the initial 15 minutes is obtained from the administrator or administrator's designee and manual restraints must not exceed four (4) cumulative hours in a 24-hour period.  Describe all techniques (including manual restraints), when techniques are NOT used and expected outcomes.  Describe the assessment of underlying or unknown medical or physical condition precluding use of restraints.  Describe the techniques of group and individual behavior management.  Describe the alternative methods of handling aggressive and assaultive behavior.  Describe the techniques for returning the child to planned activity following an emergency intervention.  As a reminder, each use of manual restraints must be reported to the Department and the child's authorized representative by telephone no later than the next working day following the incident.  The Emergency Intervention Staff Training Plan is to be included as a component of the emergency intervention plan. The plan must include the following in this section: *** (1)The type, title, and a brief description of the training that all facility personnel have completed. (2) Training requirements for new personnel. (3) The ongoing training required for existing personnel. (4) Training curriculum as specified in Section 84365(b). (5) Training schedule which identifies when staff training will be offered and provided. (6) The name(s) and qualification(s) of the instructor(s) who will provide the training.  Describe how any report of the use of manual restraints must be reviewed, for accuracy and completeness, and signed by the administrator or administrator's designee no later than the next working day following the incident.  Describe or provide a copy of the monthly log of each use of manual restraints.  Describe the procedures for an internal biannual review of the use of emergency interventions must be developed or provide a copy of the form.  Describe the procedure of when and how to involve Law Enforcement.  Describe the staff training plan and how often staff are trained and where the training is documented.  Describe how the facility shall submit reports to the Department, using form LIC 624-LE or a report containing all the information required in LIC 624-LE, regarding any incident that involves law enforcement contact with a child residing in the facility.  Describe how the licensee shall make an initial report to the Department no later than the next business day following each incident and send a written report within seven days.  Describe how within six months of the incident, the licensee shall provide a follow-up report for each incident that includes the following information: (A) The type of incident. (B) Whether the incident involved an alleged violation of any crime, other than an age-based curfew law, by a child residing in the facility. (C) Whether staff, children, or both were involved in the incident. (D) The gender, race, ethnicity, and age of children involved in the incident. (E) The outcome of the incident, if known, including arrests, removals of children from placement, termination or suspension of staff, the filing of a Welfare and Institutions Codes Section 602 petition for the child, or revocation of or changes to the terms of probation. *** Sec. # Children's Complaint/Grievance Procedures [Reference: CCR 84072.2].  Clarify who is the "designated designee," if the complaint is against the Administrator.  Describe where the outcome of the complaint/grievance is documented.  Describe where the grievance box is located.  Provide a copy of the complaint/grievance policy the child and Authorized Representative will sign in this section. Sec. # Handling Children's Funds, Allowances, and Salaries [Reference: CCR 80022(b)(12), 80025, 80026, 84026].  Provide the amount of allowance in this section.  As a reminder, Personals and Incidentals cannot be used for allowance.  Describe the amount of allowance clients can earn for chores. Sec. # Chores.  Provide a copy of the House Chore Chart in this section. Sec. # Nutrition/Sample Menu  Provide a sample menu which includes one week's worth of planned meals, including snacks from the four basic food groups;  Portion sizes; and  Times meals/snacks are served. Sec. # Staff Schedule  Provide the actual work schedule or LIC 500 in this section, which includes names, classifications, days, and hours worked.  Specify the number of hours the Administrator will be at the facility each week.  Specify the number of facilities for which the Administrator is responsible. Sec. # Staff Qualifications  Provide copies of resumes or job applications for all child care workers, social work staff, administrator, and consultants in this section. If employees have not started work, provide a letter of *** acceptance/commitment for the position.  Specify the number of hours the Administrator will be at each facility each week, performing administrative duties. Sec. # Job Descriptions  Please note the Administrator job descriptions does not have the requirements listed in the regulations for the Administrator and needs to be updated.  Provide a job description for the Social Worker.  Provide duties on all job descriptions. Sec. #24. Inservice Training for Staff/Administrator 1.Please provide the initial and annual training curricula/outline, including the trainers' name/position and their qualifications. 2.List trainers' names and qualifications for the annual training requirements. 3.Describe the 5 hours of the annual training that shall consist of course work from an entity other than the group home such as an accredited educational institution, workshops, seminars, or other direct training provided by a qualified individual, who meets the requirements specified in Section 84065(i)(4)(A)1., who is not affiliated with the group home licensee 4.Describe the training plan for the facility's manager. Please include the course titles and length of each training. 5.Describe or provide a copy of the child care staff assessment within 7 and 30 days of the completion of the 8-hour training and that it will be stored in the personnel record. 6.Describe how special training needs are identified and then training met to address. 7.Describe the training for the Reasonable and Prudent Parent Standard. 8.Describe the initial training that needs to include: (A) Overview of the client population served by the group home; (B) Facility's program and services, including program philosophy, activities and community resources; (C) Facility's policies and procedures, including reporting requirements to the Department and as a mandated child abuse reporter; *** (D) Child care workers' job description, including roles and responsibilities; (E) Child care workers' self awareness; (F) Role of other facility personnel in service delivery, including case staffing; and the role and responsibilities of the onsite staff member designated to apply the reasonable and prudent parent standard as specified in Section 84065 (b)(1); (G) Discipline policies and procedures; (H) Disaster response (I) Medical emergency response; (J) Teamwork and interpersonal communication among facility personnel and clients and client family members; (K) Teamwork and intra-facility communication; (L) The role of placement workers; (M) Medication procedures, assistance with medication, universal precautions, recognition of early signs of illness and the need for professional assistance, and other health related issues ;including oversight and monitoring of psychotropic medications for children in foster care and related topics specified in Section 16501.4(d) of the Welfare and Institutions Code; (N) Group home children's adjustment to group care; (O) Housekeeping and sanitation principles; principles of nutrition, food preparation and storage and menu planning; (P) California Code of Regulations, Title 22; (Q) Availability of community services and resources; and (R) Recreation activities and resources. (S) A child's rights as specified in Welfare and Institutions Code section 16001.9 and Section 84072, including a child's right to have fair and equal access to all available services, placement, care, treatment, and benefits, and to not be subjected to discrimination or harassment on the basis of actual or perceived race, ethnic group identification, ancestry, national origin, color, religion, sex, sexual orientation, gender identity, and gender expression, mental or physical disability, or HIV status. status. (T) Instruction on cultural competency and sensitivity relating to sexual orientation, gender identity and gender expression, and best practices for, providing adequate care to lesbian, gay, bisexual and transgender children in out-of-home care. *** (U) The facility's policies and procedures concerning when and how to involve law enforcement in response to an incident involving a child residing in the facility. 1. The training shall include the right of children in foster care to have law enforcement intervention requested only when there is an imminent threat to the life or safety of a child or another person, or as a last resort after other diversion and de-escalation techniques have been utilized; and to not have law enforcement intervention used as a threat or in retaliation against the child. (V) A child's right to receive sexual and reproductive health care and information. (W) A child's right to have their sensitive health information kept confidential (X) The duties and responsibilities of the assigned case management worker and the licensee to ensure that children can obtain sexual and reproductive health services and information. (Y) Guidance about how to engage and talk with children about healthy sexual development and reproductive and sexual health in a manner that is medically accurate, age or developmentally appropriate, trauma informed, and strengths based. (Z)Information about current contraception methods and how to select and provide appropriate referral resources and materials for information and service delivery. 9.Submit a one-month training schedule and the length of each training. Sec. #25. Administration  Provide a current organizational chart which shows lines of administrative authority; and copies of the articles of incorporation and bylaws. Sec. # Control of Real Property  Will you be living at the facility?  #2 needs to be filled out.  #4 says they will allow clients between ages 6-17, however, you stated on the LIC 200 you will have 5 children between the ages of 18-21. The lease or the LIC 200 needs to be updated so they are the same ages in all sections.  #5 needs to be filled out. *** Sec. # Facility Sketch  Include the garbage storage areas on this form.  Will the facility have a Ring doorbell or any video cameras? A copy of this report was provided to the applicant along with the signed Orientation form indicating Component II has been completed. A copy of this report will be placed in the facility file.

Deficiencies:
92501: Kb Homes Llcfacility Number: 366000054 Visit Date: 10/21/2025 Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 A8.b 	Balance Sheet (LIC 403):
	Remove crossed out sections.

   A8.c Balance Sheet Supplemental Schedule (LIC 403a):
	Provide a copy of the ownership documentation for Property #1 with the purchase price and current value.

   A10. Personnel Report (LIC 500):
	Facility Number needs to be filled out.
	Name of the person that prepared form needs to be filled out.
	We cannot approve individuals to be working 7 days per week and not have any days off.

title: Facility Name


state: CA

facility_name: KELLY'S HOME

summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13On 9/27/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a complaint investigation visit regarding the above allegation. LPA met with Administrator Rochelle Rivera and informed of the purpose of the visit. Based on confidential interviews, observations, and record review, two youth in care are above the licensed age range. The facility has provided support letters for age exceptions but had not provided a written request for age exceptions meeting licensing requirements. Licensing records reflect previous contacts, but interviews with management reflect not being aware further action was needed. Additionally, the facility is currently nearing the end of the licensure process to become an adult residential facility and has kept the licensing agency up to date on their progress with this. The preponderance of evidence standard has been met, and therefore the above allegation is substantiated. LPA determined that the violation is considered a technical violation, and no citation is being issued at this time. Administrator submitted the age exception requests on 9/26/24. An exit interview was conducted, appeal rights were provided, and a copy of this report was left with Administrator. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Mariah Hawkins 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 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE This is an official report of an unannounced visit/investigation of a complaint received in our office on 08/14/2024 and conducted by Evaluator Mariah Hawkins PUBLICCOMPLAINT CONTROL NUMBER: 14-CR- FACILITY NAME:KELLY'S HOMEFACILITY NUMBER: ADMINISTRATOR:ROCHELLE RIVERAFACILITY TYPE: ADDRESS: SHOREVIEW AVENUETELEPHONE: (650) 375- CITY:SAN MATEOSTATE: CAZIP CODE: CAPACITY:6CENSUS: 2DATE: 09/27/ UNANNOUNCEDTIME BEGAN: 01: PM MET WITH:Administrator Rochelle RiveraTIME COMPLETED:01: PM 9Staff are overmedicating resident INVESTIGATION FINDINGS: 13On 9/27/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a complaint investigation visit regarding the above allegation. LPA met with Administrator Rochelle Rivera and informed of the purpose of the visit. Based on confidential interviews, observations, and record review of medication administration records (MARs), centrally stored medication records, and other medical records, some discrepancies were found. One discrepancy was found that could reflect an overadministration of medication. The MARs reflected administration of a discontinued medication. However, inspection of the resident's medication bin, centrally stored medication records, and pharmacy orders showed that the medication had not been filled since May 2024 and was not maintained in the bin. It is not clear that this medication was administered or that an overadministration occurred. Although the allegation may have happened or is valid, based on LPA's observations and interviews, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. An exit interview was conducted, appeal rights were provided, and a copy of this report was left with Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Mariah Hawkins 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: 3 of 3

report_type: Complaint Investigation

met_with: Administrator Rochelle Rivera

complaint_status: unsubstantiated


summary: Facility Evaluation

raw_content:
Narrative:
At 9: AM Licensing Program Analysts (LPA) Isabel Mendoza made an unannounced inspection to this facility to conduct an annual required inspection. LPA met with Direct Care staff John Yap and Lead Staff Daisy Garcia. Shortly after Administrator Rochelle Rivera arrived. The facility currently has a census of 3 clients. All clients were in school during todays inspections. At 9: AM LPA and the Administrator toured the facility inside and out. The facility is clean, safe and sanitary and in good repair. All passageways are unobstructed. All disinfectants, cleaning solutions and poisons are locked in the laundry room. Per Administrator, there are no firearms in the facility. The kitchen is clean and sanitary. The facility has sufficient two day perishable and seven day nonperishable food supply. The inspected bedrooms were furnished accordingly. LPA noticed that two bedrooms (bedrooms 2 and 3) ceilings and walls had several stains/markings, so LPA advised the facility to do a good cleaning on the walls/ceiling. During inspection at 11: AM staff started wiping down the walls in both bedrooms. There is an outdoor space for the clients, and no hazards or broken items. The facility has another house/detachment which is separate from the facility. This area is prohibited from clients and is used by staff members/live-ins. LPA advised the facility to submit an updated fire clearance sketch and include the backyard detachment house. The facility will submit the sketch no later than 10/01/21. There are no pools or bodies of water. LPA inspected medications, and they appeared fine. Medications are located in the kitchen area [ PLEASE REFER TO LIC C...] in a locked cabinet. All items are fully documented. LPA noticed that the facility was using MAR LIC A for psychotropic medication. LPA gave a copy of LIC B to the Administrator so the facility can separate non-psychotropic from psychotropic MARS per requirements. The facility ensured they will start incorporating the LIC 622B, and make all necessary changes. LPA Mendoza reviewed all three client files. All files were organized and had all required documents. LPA found a few items were documents were not fully complete, so LPA reminded the facility to ensure that all LIC forms must be completed and if an item does not apply to write "N/A". At 12: PM LPA inspected three staff files and (S1), (S2), and (S3) (Please refer to LIC 811, dated 09/17/21 for confidential names) did not have Health Screening or TB test results on file. The administrator confirmed that all three staff member have not and they will make an appointment. All staff have required training on file. The Administrator (S4) certificate expired back in 2018 and the Administrator stated that she tried to renew it in 2019 but did not complete the correct administrator courses, so was unable to get it renewed. LPA obtained copies of all documentation that was submitted back in 2019. During inspection, the Administrator confirmed she is currently registered for a recertification class that will be on 09/22/21 and submitted proof to LPA. LPA went over Guardian association list that was printed on 09/16/21 with Administrator, and (S5) Daisy Garcia is not showing associated. The facility confirmed that (S5) has worked at the facility for about 5 months. During inspection, LPA obtained a copy of criminal record transfer request, which was submitted to CCL main office back in April. LPA advised the facility to resubmit form to CCL main office again, and LPA obtained a copy and will take back to the office for processing. LPA Mendoza also introduced Administrator to CCL's new background portal called Guardian. LPA obtained copies of LIC 500, LIC 610, LIC 309, and Administrative documents for Rochelle Rivera. Per Title 22 regulations, deficiencies were cited at this visit, and three LIC Technical Violations, and one Technical Assistance was issued. Exit interview conducted, appeal rights printed, and a copy of this report was left with the Administrator.

report_type: Facility Evaluation

visit_type: Annual

met_with: Adminstrator, Rochelle Rivera


summary: Facility Evaluation - 2 deficiencies

raw_content:
Narrative:
On 9-29-22 10:10AM, Licensing Program Analysts George Karkazis conducted an unannounced Annual/Required inspection at the listed facility. LPA's met with Co-Administrator Adora Ancheta and toured the facility inside and out. Safety precautions were taken, including screening call and mask-wearing. The Group Home is licensed to serve 6 clients. Present during the inspection were two staff and no clients present. All clients were at school and all clients are non-verbal. At 11:03AM, LPA Karkazis toured the facility. LPA Karkazis observed five bedrooms and three bathrooms. LPA observed the facility license, personal rights, facility sketch, meal menu, and other forms posted on the walls throughout the facility. LPA Karkazis tested the water temperature and found it to be 110 degrees, which is within range. The thermostat read 68 degrees which is within range. Sharps were locked, and chemicals were safely stored. There were two days of perishable foods and seven days of non-perishable foods present. The medication was also stored and locked cabinet. LPA checked medication and found no issues. The facility is in good repair and clean. LPA Karkazis interviewed two staff and no clients. At 12:20PM LPA Karkazis toured the backyard. There were no open bodies of water. The backyard was in good repair and clean. At 1: PM LPA Karkazis reviewed client and staff files. Client files were complete and had all required documents. LPA Karkazis reviewed staff files and the following items were missing: (S1) did not have a current CPR training certificate, (S2) had no first aid training, fingerprint clearance, no education history, no personnel record, no job application, no health screening, no medical training, no tuberculosis clearance. (S3) had no first aid training certificate, valid fingerprint clearance, education history, health screening, employee rights, medical training, and tuberculosis clearance. (S4's) CPR certificate expired. (S5)had no first aid certificate, personnel record, no health screening, no training record, no education history, and no tuberculosis clearance. Also, staff (S3) was present at the facility and was not associated to the facility. The Co-Administrator showed LPA a copy of the DOJ Applicant Fingerprint Response sheet, however, (S3) was not showing associated to the facility nor had a profile on Guardian. At this time, there were deficiencies cited, Title Group Home Regulations 84365(d)(1), 84365(d)(1)(A Emergency Staff Intervention Training, 84365(d)(1)(B), 84365(d)(1)(C) Emergency Staff Intervention Training, 80066(a)(3),80066(a)(10) Personnel Records, 80066(a)( Health Related Services, 80075(f) Personnel Records, 80066(a)(5, 80066(a)(6) Personnel Records, and 80019(e) Criminal records clearance, civil penalty assessed. An exit interview was conducted, appeal rights discussed, and a copy of this report was given to Adora Ancheta, Director.

Deficiencies:
80075(f): Deficient Practice Statement
1
2
3
4Based on record review,the licensee did not comply with the section cited above, have not received first aid training from qualified agencies,which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2022
Plan of Correction
1
2
3
4All staff shall  have qualified first aid training, with certificates on file.
80019(e): Deficient Practice Statement
1
2
3
480019(e) Criminal Record Clearance-All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility.

met_with: Adora Ancheta, Director

title:
Health-Related Services

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

This requirement is not met as evidenced by


summary: Facility Evaluation

raw_content:
Narrative:
On 8/31/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a required annual inspection. LPA met with Administrator Rochelle Rivera, and informed of the purpose of the visit. The CARE Inspection Tool was used to completed this inspection. During inspection, LPA toured the facility site and inspected facility records. LPA observed the facility to be clean. No hazards were observed. The kitchen is fully stocked with food within date. Bedrooms have clean linens. Bathrooms are maintained in sanitary condition. A continuation visit is required to complete this inspection. LPA observed the following deficiencies during today's inspection: - Staff S1 (See LIC Confidential Names) does not have a background clearance. - The facility has not completed emergency drills in at least 8 months. - All four residents are above the licensed age range, and the facility has not been granted age exceptions. - There was no current register/roster of residents, and licensee needed to generate a new one. - The facility manager (S1) personnel file did not include facility manager training, and administrator stated the training plan in the plan of operation (POO) was not followed. - The personnel file for staff S2 did not reflect 20 hours of annual training nor any training since January 2022. - The file for resident R4 did not contain medical consent forms nor a medical assessment/physician's report. LPA is issuing citations of Health and Safety Code, Section 1565(c) and (e) and California Code of Regulations, Title 22, Sections 80019(e), 80010, 84065(d) and (j), 84070(b), and 80069. See attached LIC 809-D pages. Additionally, LPA is assessing a civil penalty of $3000, pursuant to Section 80019, for the second criminal record clearance violation in 12 months. See LIC 421BG. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Rochelle Rivera, whose signature on this form confirms receipt.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 9/7/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted an annual continuation inspection, continuing from the 8/31/23 inspection. LPA met with Administrator Rochelle Rivera and informed of the purpose of the visit. During visit, LPA interviewed two staff and reviewed four client files and 1 staff file. Using the CARE Inspection Tool to complete this inspection, LPA observed the following deficiencies: - Medication administration was not logged on 9/6/23 or 9/7/ AM. Medication counts and staff statements reflect that medication was administered. - Staff S3 (See LIC Confidential Names, dated 9/7/23) file did not contain a LIC 501, a LIC 503, or mandated reporter acknowledgement form. Record review and interview indicated that mandated reporter training and first aid training are needed. - The administrator does not have a valid group home administrator certificate, and evidence of completion of the 40 hours of administrator continuing education could not be supplied during visit. The facility was previously cited for administrator certification on 09/17/2021. - Resident files were missing required documentation. R1 and R2 cash resources logs were blank for August 2023, and the cash balances did not match the last logged amount, even accounting for August receipts. Additionally, the personal property and valuables logs were missing for R1 and R4 and had not been updated since 2017 for R2 and R3. R1, R2, and R3 files did not contain current care plans (IPP/ISP), and R4's file did not contain any plans. Administrator supplied a current plan for one resident, but there was no evidence it had been trained on and implemented due to needing to be located in email. LPA is issuing citations for the above deficiences of Title 22, Sections Children's Records, Personnel Records, Personnel Requirements, Health-Related Services, Administrator Qualifications and Duties, Client Records, and 84068. Modifications to Needs and Services Plan. See attached LIC 809-D pages. Additionally, due to repeat violations within 12 months of sections 80075(f), 80066(a)(6), and 80066(a)(10), LPA is assessing civil penalties of $250 for each violation, totaling $750. See LIC 421FC pages. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Rochelle Rivera, whose signature on this form confirms receipt.

Deficiencies:
84068.3(a): Modifications to Needs and Services Plan

(a) The needs and services plan specified in Section 84068.2 shall be updated at least every six months to determine the following

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On Monday, September 25, 2023 (09/25/23), a scheduled office meeting was held with the licensee to discuss the licensee's current population and the facility's plan to either transition the residents to adult homes or convert the facility into an adult residential facility (ARF). In attendance were Licensing Program Manager (LPM) Lidia Tinoco, Licensing Program Analyst (LPA) Mariah Hawkins, Administrator Rochelle Rivera, Director Adora Ancheta, and Golden Gate Regional Center (GGRC) Social Workers Martha Tercero, Anita Yen, and Blanca Rivera del Valle. The facility currently has three residents in care whose ages exceed the facility's licensed age range. The licensee was instructed to submit age exception requests with placement agency support letters, and all were received this month. The licensee stated they will be converting the home into an adult home. The licensee agreed to complete the following: 1) By Friday 10/27/23, the licensee will submit their ARF application to the CCLD Adult & Senior Care Program Centralized Application Bureau. 2) Following submission of the ARF application, the licensee will send LPA the assigned license number for the ARF application so that LPA may check in internally on the application review. 3) The licensee will continue to provide monthly updates until the ARF has been licensed. A copy of this report was provided to Administrator Rochelle Rivera, whose signature on this form confirms receipt.

met_with: Director Adora Ancheta, Administrator Rochelle Rivera


summary: Facility Evaluation

raw_content:
Narrative:
On 03/14/24 at 9:45AM, Licensing Program Analysts (LPAs) Celeste Aparicio and Mariah Hawkins conducted a quarterly case management inspection, per the agreed upon terms of the December 2023 noncompliance conference (NCC). LPAs met with Licensee Adora Ancheta and acting Administrator Rochelle Rivera and informed both on the purpose of this visit. Per the NCC terms, the facility was to be subject to quarterly inspections at which personnel and resident records will be reviewed for completion. In addition, the facility was to designate a qualified and currently certified administrator, and to implement interview review of records conducted by the licensee or director with documentation of the review available on site. Lastly, the facility is to maintain overall compliance with applicable regulations. At visit, LPAs reviewed all personnel and resident records and observed them to be complete. Administrator Rivera agreed to submit R3's current IPP and ISP to LPA Aparicio by 3/15/24 at 4:30PM. LPAs observed that Administrator Rivera has completed the required administrator continuing education hours and submitted an administrator recertification application to the Department in October 2023, which the Department has not yet processed. LPAs advised the licensee that technically the acting administrator is not currently certified. See LIC 9102. An exit interview was conducted, appeal rights were discussed, and a copy of this report was left with Administrator Rochelle Rivera, whose signature on this form confirms receipt.

met_with: Rochelle Rivera


summary: Facility Evaluation

raw_content:
Narrative:
On 6/7/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management inspection. LPA met with Facility Manager Dela Luna at the facility and Administrator Rochelle Rivera over the phone and informed of the purpose of the visit. Per the December 2023 noncompliance conference (NCC), the following conditions apply and/or shall be met: 1) The facility shall be subject to quarterly case management inspections. Today is the facility's 2nd quarterly inspection. 2) Personnel records shall be complete with background clearance documentation, initial training, annual training, intervention training, first aid training, mandated reporter training. LPA observed all staff listed on the LIC 500 to have a background clearance. All files were complete, and all staff have valid first aid and CPI intervention certifications and have complete annual, initial, and other required training. 3) Resident records shall be complete with accurate cash/valuables records and current care plans updated at least every 6 months. LPA observed all resident files to be complete, including care plans updated within the last 6 months and detailed and accurate cash/P&I records. 4) Monthly reviews, beginning January 2024, of all personnel and resident records conducted by the director/licensee shall be documented and available on site. LPA observed all personnel and resident files to be complete and the main facility binder to be current and up to date. Administrator agreed to create a specific checklist to document the administrative review by Administrator and/or Director. See Lic 809-c. 5) Administrator shall have complete training and certification. Administrator has a valid administrator certificate reflecting complete administrator training. 6) The facility shall be maintained in compliance. The licensee was required by the fire department to complete work on the physical plant. An inspection was conducted by the fire department on 5/29/24, and per Administrator, only small corrections are still needed. Administrator agreed to send LPA the list of needed corrections once received. Lastly, all residents in care are above the facility's licensed age range. However, age exception requests are pending, and the facility is actively working towards adult residential facility licensure. No deficiencies were observed during the tour of the facility and grounds nor during review of facility records. No citations were issued at today's visit. An exit interview was conducted, and a copy of this report was left with Facility Manager Conrado Dela Luna, whose signature on this form confirms receipt.

met_with: Facility Manager Conrado Dela Luna


facility_name: KEY HOUSING

summary: Facility Evaluation

raw_content:
Narrative:
On 09/28/2021 at 9: AM Licensing Program Analyst (LPA) Zena Phillips made an unannounced visit to Key Housing for the purpose of an Annual/Required Licensing Inspection. LPA Phillips met with Artis Carhee 111/Program Director and conducted a tour of the facility. There is currently 1 child placed in the facility. The program accepts clients from Private Placement's. This GH is licensed to serve 6 children ages 13-17 years of age, ambulatory only. The facility is located in a residential area a two story residence , 3 bedrooms, 3 1/2 bathrooms, kitchen/dining room, 1 laundry room , den area with ample outdoor space. There was adequate closet and storage space for the clients. Overall, the facility appeared clean, safe and sanitary. The building is in good repair. The Facility has Office space for the Administrator and staff. All beds are in good repair. Each client has adequate closet and ample clothing. Each client has complete sets of towels, sheets, blankets and bedspreads. There is adequate hygiene and grooming supplies in client's bedroom. The kitchen is sanitary and in good repair. A physical plant inspection was completed and included the following checks: Facility is clean, safe, sanitary and in good repair. LPA Phillips conducted confidential interview with Program Director and resident present at facility. There were no deficiencies cited at this time. LPA will return to interview additional staff and that were not present during the initial inspection. Exit Interview was conducted and a copy of this report was left at facility

met_with: Artis Carhe/Program Director


summary: Facility Evaluation

raw_content:
Narrative:
On 09/29/2021 at 10:10AM, Licensing Program Analyst (LPA) Zena Phillips made an announced visit to Key Housing for Annual Continuation licensing Inspection. LPA met with Artis Carhee 111, Program Director who granted access to the facility. LPA Phillips reviewed the following during the inspection: Staff records review and client record review.. LPA Phillips observed first aid kit, fire extinguisher, and private bathroom. Facility vehicles was operable, clean, free of damage and had current registration and insurance. LPA reviewed Criminal Records and confirmed that all current staff were cleared. LPA Phillips reviewed staff records and client records. LPA interviewed staff present during this inspection. Only i staff file had mandatory reporter training and current CPR card. All other staff files did not have complete required documents. LPA Phillips advised Artis Carhee Program Director of the missing required documents for staff files. LPA Phillips advised training certificates, job duties . Program Director stated would update filed immediately and add required documents to file.


summary: Facility Evaluation

raw_content:
Narrative:
On 11/16/2023 at 09: AM, (LPA) Licensing Program Analyst - Dennis Jarmin made an unannounced visit to Key Housing Group Home to conduct the annual required inspection. LPA met with Jack Muldoon, Program Director, who granted access to the facility. LPA then inspected the entire physical plant of the facility. The Group Home is licensed and provides care and supervision for six (6) children, ages 12-17, Ambulatory only. There are no bodies of water on the premises and security camera surveillance are placed outside area of the home. The Group Home Administrator confirmed that there are no guns or weapons stored on the premises. The facility is a two story home with 3 bedrooms and 3 full bathrooms plus 2 (1/2) bath. LPA observed the facility clean and sanitized with clean linens, appropriate drawer storage and closet available for clients clothing. The 3 and 2 (1/2) bathrooms were observed clean and sanitary with the required hot water temperature within the regulation. The dining room and living room area had appropriate seatings, and furniture were in good repair condition. The facility has central air conditioning unit that provides suitable air temperature throughout the home with appropriate lighting. LPA observed all the windows in good condition and observed 5 window screens that had tears but a work order to replace the screens today was submitted today. There were no bars on the windows in the event of an emergency evacuation and all passageway, stairs and porches were clear of obstruction and debris. All required posting were met (meal plan, daily activities, required licenses and regulations, personal rights and emergency disaster plan) that are posted in the common area readily accessible to clients. LPA observed cleaning supplies solutions, bleaches and disinfectants are properly stored under the sink that is locked. Sharp knives were also observed locked and inaccessible on a separate cabinet. All the clients prescribed medications are in locked cabinet in the administrative office. LPA observed 8 battery operated smoke detectors and Carbon Monoxide, tested by the facility manager to be operable and audible. The garage is use for inside activity area and there is an on-site laundry area to the rear side of the house that is maintained cleaned and sanitized. The facility has a working telephone and clients can use the telephone when needed. There are appropriate supply of perishable (2 days) and (7 days) non perishable food. Clients are accorded dignity in personal relationships with staff and others. The Facility operates within license conditions and limitations including capacity limitations. Facility has a current, written plan of operation. Facility personnel are instructed to report violations of personal rights. Licensee will report changes in the plan of operation affecting service to clients. Licensee will report client injuries requiring medical treatment and other incidents. LPA conducted two (2) Staff interviews and no Client interviews due to clients are all in school. LPA reviewed eight (8) Personnel files and five (5) Client records. During this inspection, LPA observed the facility to be clean, safe and sanitary. There were no deficiencies cited at this time only technical advisory. Exit Interview was conducted, and a copy of this report will be emailed to Evan Powell.

met_with: Jack Muldoon


facility_name: KEY TREATMENT 1, LLC

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Statements indicated that the property owner is currently working with the City of Malibu to make the corrections and add a garage to the facility. There were no witnesses or statements to corroborate that Licensee was made aware of conversion or citation issued. Due to lack of evidence obtained during the investigation, LPA determines that the allegation is Unsubstantiated. Although the allegation may have happened or are 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 facility with the Program Director Matthew Cox Program.

Investigation Findings:
13On July 18, 2024, 11: AM, Licensing Program Analyst (LPA), Rosslyn Gray made an unannounced visit to conclude the complaint investigation. Prior to entering the facility LPA Gray conducted a health and safety risk assessment. During the investigation, LPA Gray conducted confidential interviews, reviewed documentary evidence and photos. Licensee denied knowledge of the allegation. Based on confidential interviews and review of documentary evidence, statements were inconsistent. Documentary evidence indicated that during the pre-licensing inspection and fire inspection no garage was observed, and the facility was not found to have any compliance or safety concerns. Statements indicated that the property owner did not disclose to the Licensee that the garage was converted into a sound room when facility was leased. Statements indicated that the property owner completed this conversion without authorization from the City of Malibu and received a citation December 12, 2022. 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 EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: KEY TREATMENT 1, LLCFACILITY NUMBER: VISIT DATE: 07/18/2024

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

met_with: Mathew Cox Program Director


raw_content:
Investigation Findings:
13On July 17, 2025, at 1:15PM, Licensing Program Analyst, (LPA), Justine Armstrong conducted an unannounced visit to the Key Treatment 1, LLC facility for the purpose of delivering findings for a complaint investigation alleging, 1) Staff did not provide adequate supervision, resulting in minors having inappropriate sexual interactions. 2) Staff did not intervene when minors had altercations with each other, and 3) Staff made an inappropriate comment to a minor. This complaint was received by the Department on February 7, 2024. Upon arrival, LPA was granted access to the facility by the Executive Director Elnaz Mayeh. This amended report reflects the original findings that were previously reviewed with and signed by the facility on January 23, 2025. The report is now being issued as the official version. The investigation conducted by LPA K.Dear included confidential interviews, as well as a review of incident reports, supervision logs, and other relevant documentation. Concerning the supervision issues, both interviews and documents did not support the claim that staff failed to adequately monitor clients. The statements provided were inconsistent and lacked corroborating evidence. Additionally, the allegation that staff failed to intervene during peer altercations was not substantiated; both records and interviews indicated that staff responded appropriately to these incidents. Lastly, the claim that a staff member made an inappropriate comment to a minor could not be confirmed. The statements were conflicting, and no witnesses were able to verify the allegation. Based on the confidential interviews and review of documentary evidence collected by LPA K.Dear, the Department has decided that the allegations are Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. If any additional information is received, this complaint can be amended, and the findings can be changed. An exit interview was conducted with Facility Executive Director, and a copy of this report was provided. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Enrique M Hernandez LICENSING EVALUATOR NAME: Justine Armstrong 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: Elnaz Mayeh


raw_content:
Investigation Findings:
13On July 17, 2025, at 1:15PM, Licensing Program Analyst, (LPA), Justine Armstrong conducted an unannounced visit to the Key Treatment 1, LLC facility for the purpose of delivering findings for a complaint investigation alleging, (1) Staff forced minor in care to sleep on the floor (2) Staff did not provide adequate services to minor in care. This complaint was received by the Department on January 16, 2025. Upon arrival, LPA was granted access to the facility by the Facility Executive Director Elnaz Mayeh. The investigation conducted by LPA J. Armstrong included confidential interviews with staff and relevant documentation.Documentary evidence confirmed that staff did not force the minor in care to sleep on the floor. Furthermore, the allegation that staff did not provide adequate services to the minor was not supported, as records and interviews revealed inconsistent statements that could not be corroborated by evidence. The conflicting statements provided did not have any witnesses to verify the allegations. Based on the confidential interviews and review of documentary evidence collected by LPA J. Armstrong, the Department has decided that the allegations are Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. If any additional information is received, this complaint can be amended, and the findings can be changed. An exit interview was conducted with Facility Executive Director, and a copy of this report was provided. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Enrique M Hernandez LICENSING EVALUATOR NAME: Justine Armstrong 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:


summary: Facility Evaluation

raw_content:
Narrative:
On February 8, 2023 @ 10: AM Licensing Program Analyst (LPA) Zena Phillips conducted Component II - Face to Face meeting with KEY TREATMENT 1, LLC at the El Segundo Regional Office. The purpose of the meeting was to discuss the review of the Program Statement. The following individuals were present: Zena Phillips, Licensing Program Analyst and Evan Powell, Applicant. The Program Statement has been reviewed. Revisions are required as outlined below. Please make the required revisions and submit additional documents by February 22, 2023, unless arrangements for an extension are made prior to that date. Section 4: List of Community Resources, provide daily activity schedule for one week including weekends Section 6: Medical: Provide details on destroying medications Section 13: Discipline Policy: Level System: Provide details on time frame staff will transition to another level. Include the name and qualifications of who designed Emergency Intervention Plan. Section 15: Runaway Plan: Must notify CCL by submitting incident report. If Law Enforcement contacted must submit Law Enforcement report to CCL. Section 16: Children's Complaint/ Grievance Procedures: Can a complaint be filed anonymously? Please explain. continued on 809 c Section 19: Nutrition/Sample Menu: Provide sample menu. Section 21: Staff Schedule: Specify number of hours program administrator will be at the facility. Section 22: Staff Qualifications: Provide copies of resume for administrator. Provide number of hours administrator will be at each facility performing administrator duties. Resubmit LIC 500 with job titles should match LIC 500. Section 24: In Service Training for Staff : Please explain who will do training. Initial training and annual training with curricula. Describe training plan for facility manager. . Missing documents: . Submit Surety Bond with seal First Aid Certificate: A copy of applicants driver's license was made during visit. Provided information for Group Home Orientation contact for Riverside office. Provided administration required documentation. Advised applicant will conduct pre licensing inspection visit tentatively on March 2, 2023. .

met_with: Evan Powell/ Applicant


summary: Facility Evaluation

raw_content:
Narrative:
On 03/02/2023 @ 9: AM Licensing Program Analyst (LPA) Zena Phillips made an announced visit to KEY TREATMENT 1, LLC for the purpose of conducting Pre Licensing inspection. LPA Phillips was greeted by Evan Powell/ Administrator who granted access and provided a tour of the entire facility. The facility is a two story structure with five (5) bedrooms and three and half bathrooms (3.5) located in a residential neighborhood. Current census is 0. Facility kitchen has double sink with garbage disposal, dishwasher, adequate cabinet and drawer space for dishes, utensils, and food storage. There is a large refrigerator and freezer combo in the kitchen with sample menu posted next to refrigerator. The sharps will locked away in the staff office and used the facility chef. The stove top has six (6) burners and LPA Phillips observed all burners functioning properly. There is a working hardline phone located in the kitchen, one of four fire extinguishers located on west facing wall of dining area. Next to the kitchen there is small staff dining area with seating for six (6) and LPA Phillips observed laminated and wall mounted personal rights poster. Emergency Disaster Plan posted on staff dining room wall. There is common area with covered non- operable fireplace. LPA Phillips observed large sofa and chairs, tables, lamps with adequate seating for twelve (12). There is half bathroom downstairs for staff use. LPA Phillips observed next to front door storage closet with adequate hygiene products, paper goods. There is second locked storage room for cleaning supplies to the right of the stairs. The first bedroom downstairs has two (2) double beds with clean linens, lamps, table, wall mounted television and six (6) drawers with adequate closet space for storage. cont on 809 c Report amended on 03/09/2023 to correct wording of pool gate lock. Laundry room has washer, dryer and additional refrigerator and freezer combo storage. This room is locked with locked cabinets for medicine storage and three (3) first aide kits including thermometer. There is working sink with counter adequate storage for laundry products. Second bedroom has two (2) double beds with clean linens, table, lamps, wall mounted television. LPA Phillips observed two full bathrooms downstairs to have tub and shower combo, toilet and sink. Water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. LPA Philips observed the upstairs bedroom with two(2) double beds with clean linens, six (6) drawers, tables, lamps, full bathroom attached, and adequate closet space for storage. LPA Phillips observed the facility's eight (8) working smoke and carbon monoxide detector. LPA Phillips requested Administrator test of alarm and confirmed working. LPA Phillips observed water shut off valve to the left of the front door. The gas line is down the path to the right of the from entrance clearly marked. The front entrance is landscaped, and clear of any debris. The rear of the facility has large wooden deck with tables and chairs with adequate seating for twelve (12) or more. The lower deck to the right facing the ocean has seating for eight (8) with large lounge chairs and table. The lower desk to the left facing the ocean has seating for eight( 8) with large lounge chairs. There is an additional upper deck to the left of facility with seating for six (6). All windows are in good repair with screens and blinds. LPA Phillips observed the facility has four (4) fire extinguishers fully charged and wall mounted. The facility has a pool with self- latching gate and sel closes and LPA Phillips observed gate height to be within compliance requirements .LPA observed facility exterior grounds to be landscaped, maintained and clear of all debris. LPA Phillips observed the facility to clean , safe and sanitary and license ready. An exit Interview was conducted, and a copy of this report will be emailed to the Evan Powell/ Administrator.

visit_type: Prelicensing

met_with: Evan Powell/ Adminstrator


summary: Facility Evaluation

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Narrative:
On 06/08/2023 @ 10: AM Licensing Program Analyst (LPA) Zena Phillips made an unannounced visit to KEY TREATMENT 1, LLC for the purpose of conducting Post Licensing inspection. LPA Phillips was greeted by Matthew Cox/ Program Director who granted access and provided the current census. LPA Phillips requested LIC 500 and client roster. The facility is a two story structure with five (5) bedrooms and three and half bathrooms (3.5) located in a residential neighborhood. Current census is 6. During the inspection LPA Phillips conducted four (4) confidential interviews, reviewed five (5) staff files, and five (5) client files. LPA Phillips observed files to be in compliance. Facility kitchen has double sink with garbage disposal, dishwasher, adequate cabinet and drawer space for dishes, utensils, and food storage. There is a large refrigerator and freezer combo in the kitchen with weekly menu posted next to refrigerator. The sharps are locked away in the staff office and used the facility chef. The stove top has six (6) burners and LPA Phillips observed all burners functioning properly. There is a working hardline phone located in the laundry room, one of four fire extinguishers located on west facing wall of dining area. Next to the kitchen there is small staff dining area with seating for six (6) and LPA Phillips observed laminated and wall mounted personal rights poster. Emergency Disaster Plan posted on staff dining room wall. Complaint box to submit anonymously concerns located near staff dining area/multi purpose room. There is common area with covered non- operable fireplace. LPA Phillips observed large sofa and chairs, tables, lamps with adequate seating for twelve (12). There is half bathroom downstairs for staff use. LPA Phillips observed next to front door storage closet with adequate hygiene products, paper goods. There is second locked storage room for cleaning supplies to the right of the stairs. . cont on 809 c The first bedroom downstairs has two (2) double beds with clean linens, lamps, table, wall mounted television and six (6) drawers with adequate closet space for storage Laundry room has washer, dryer and additional refrigerator and freezer combo storage. This room is locked with locked cabinets for medicine storage and four (4) first aide kits including thermometer. There is working sink with counter adequate storage for laundry products. Second bedroom has two (2) double beds with clean linens, table, lamps, wall mounted television. LPA Phillips observed two full bathrooms downstairs to have tub and shower combo, toilet and sink. Water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. LPA Philips observed the upstairs bedroom with two (2) double beds with clean linens, six (6) drawers, tables, lamps, full bathroom attached, and adequate closet space for storage. LPA Phillips observed the facility's eight (8) working smoke and carbon monoxide detector. LPA Phillips requested test of smoke detector and confirmed operational. LPA Phillips observed fire drill roster with date and participants. All windows are in good repair with screens and blinds. LPA Phillips observed the facility has four (4) fire extinguishers fully charged and wall mounted. LPA Phillips requested Board Meeting minutes to be emailed at a later date, Program Director agreed to email. The facility has a pool with self latching locked gate and LPA Phillips observed gate height to be within compliance requirements LPA observed facility exterior grounds to be landscaped, maintained and clear of all debris. LPA Phillips observed the facility to clean, safe and sanitary. An exit Interview was conducted, and a copy of this report will be emailed to the Evan Powell/ Administrator.

met_with: Matthew Cox/Program Director


summary: Facility Evaluation

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Narrative:
On 12/27/2023 @ 11: AM Licensing Program Analyst (LPA) Zena Phillips made an unannounced visit to KEY TREATMENT 1, LLC for the purpose of conducting Case Management Inspection due to incident dated 11/04/2023. LPA Phillips was met by Matthew Cox/Program Director who granted access to the facility. During this inspection LPA Phillips verified placement status and requested documents including, incident reports for November 2023 concerning Client #1 (refer to LIC Confidential Names form, dated 12/27/2023). LPA Phillips conducted one confidential interview, all other will be interview at a later date. Please email requested information to LPA Phillips at zena.phillips@dss.ca.gov. LPA Philips further requested a copy of Client Roster (obtained during visit) Personnel Schedule (LIC 500 to emailed). This case management requires further investigation. A copy of this report will be emailed to Matthew Cox/Program Director.


summary: Facility Evaluation

raw_content:
Narrative:
On 3/07/2024 @ 10: AM Licensing Program Analyst (LPA) Zena Phillips made an unannounced visit to KEY TREATMENT 1, LLC for the purpose of conducting Annual inspection. LPA Phillips was greeted by Matthew Cox/Program Director who granted access and provided the current census. LPA Phillips requested LIC 500 and client roster and both provided at time of inspection. The facility is a two-story structure with five (5) bedrooms and three and half bathrooms (3.5) located in a residential neighborhood. The facility is currently using three (3) bedrooms for clients. Current census is two(2). During the inspection LPA Phillips conducted four (4) confidential interviews, reviewed three (3) staff files, and two (2) client files. The files were electronic and reviewed with Program Director. LPA Phillips observed files to be in compliance. The facility kitchen has double sink with garbage disposal, dishwasher, adequate cabinet and drawer space for dishes, utensils, and food storage. There is a large refrigerator and freezer combo in the kitchen with weekly menu posted next to refrigerator. The sharps are locked away in the staff office and used by the facility chef. The stove top has six (6) burners and LPA Phillips observed all burners functioning properly. There is a working hardline phone located in the laundry room, one of four fire extinguishers located on west facing wall of dining area. Next to the kitchen there is a small staff dining area with seating for six (6) and LPA Phillips observed laminated and wall mounted personal rights poster. Emergency Disaster Plan posted on staff dining room wall. Complaint box to submit anonymously concerns located near staff dining area/multipurpose room. cont on 809 c There is a common area with covered non- operable fireplace. LPA Phillips observed large sofa and chairs, tables, lamps with adequate seating for twelve (12). There is half bathroom downstairs for staff use. LPA Phillips observed next to front door storage closet with adequate hygiene products, paper goods. There is a second locked storage room for cleaning supplies to the right of the stairs. The first bedroom downstairs has two (2) double beds with clean linens, lamps, table, wall mounted television and six (6) drawers with adequate closet space for storage. The laundry room has washer, dryer and additional refrigerator and freezer combo storage. This room is locked with locked cabinets for medicine storage and four (4) first aide kits including a thermometer. There is a working sink with counter adequate storage for laundry products.The second bedroom has two (2) double beds with clean linens, table, lamps, wall mounted television. LPA Phillips observed two full bathrooms downstairs to have tub and shower combo, toilet and sink. The water temperature measured within safe temperatures, at not less than 105 and did not exceed 120 degrees Fahrenheit. LPA Philips observed the upstairs bedroom with two (2) double beds with clean linens, six (6) drawers, tables, lamps, full bathroom attached, and adequate closet space for storage. LPA Phillips observed the facility's eight (8) working smoke and carbon monoxide detectors. LPA Phillips requested a test of smoke detector and confirmed operational. LPA Phillips observed fire drill roster with date and participants. All windows are in good repair with screens and blinds. LPA Phillips observed the facility has four (4) fire extinguishers fully charged and wall mounted. LPA confirmed smoke detector working properly as staff tested alarm. The facility has a pool with self latching locked gate and LPA Phillips observed gate height to be within compliance requirements LPA observed facility exterior grounds to be landscaped, maintained and clear of all debris. LPA reminded Matt Cox of reporting requirements. LPA Phillips observed the facility to be clean, safe and sanitary. An exit Interview was conducted, and a copy of this report will be emailed to the Evan Powell/ Administrator & Matt Cox/Program Director.

met_with: Matt Cox/Program Director


summary: Facility Evaluation

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Narrative:
On May 7, 2026 at 9:30am, Licensing Program Analyst (LPA) Emelyn Sanchez P. made an unannounced visit to Key Treatment 1, LLC for the purpose of conducting a Case Management - Other visit. LPA Sanchez P. met with Elayna Bray, Program Director and was granted access into the facility. The facility is a private pay treatment program licensed to provide care and supervision services to six (6) children, ages 12-17 years old, ambulatory only. There is a swimming pool on the premises which meets licensing requirements. The census at the time of the visit was six (6). LPA Sanchez P. amended licensing reports visit from 04/16/2026 and obtained signatures during today's visit. An exit interview was conducted with Elayna Bray, Program Director and a copy of this report was left at the facility.

met_with: Elayna Bray, Program Director


facility_name: KIDS FIRST ALBORADA

raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Lidia Tinoco conducted an unannounced visit to the Kids First Alborada Group Home in Visalia in order to deliver the findings of the above allegations and met with Amanda Chairez, Administrator. On July 8, 2021 the above allegation was referred to Community Care Licensing for investigation. The investigation included interviews, facility inspection and a review of facility and children's records. The complaint alleged that group home staff inappropriately restrained youth. Based on the interviews conducted and the information reviewed there is not a preponderance of evidence to prove the allegation occurred. Therefore, the allegation is UNSUBSTANTIATED at this time. A copy of this report was discussed and provided to Amanda Chairez 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 2

met_with: Amanda Chairez


raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Lidia Tinoco conducted an unannounced visit to the Kids First Alborada Group Home in Visalia in order to deliver the findings of the above allegations and met with Amanda Chairez, Administrator. On June 30, 2021 the above allegation was referred to Community Care Licensing for investigation. The investigation included interviews, facility inspection and a review of facility and children's records. The complaint alleged that a child in placement received an unexplained bruise while in care. Although the minor did have a bruise, there is no evidence to show how it happened. Therefore, the allegation is UNSUBSTANTIATED at this time. A copy of this report was discussed and provided to Amanda Chairez 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 2


summary: Facility Evaluation - 4 deficiencies

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Narrative:
An unannounced annual inspection was conducted by Licensing Program Analysts (LPA's) Lidia Tinoco, Cynthia Galindo, and Vanessa Galvan traveled to Kids First Alborada in Visalia, CA. LPA's met with Administrator Amanda Chairez and inspected the facility, inside and out. A physical plant inspection was completed and included the following checks. Adequate indoor and outdoor activity space and materials observed. The facility is maintained at 75 degrees. All facility smoke detectors are in appropriate working order, fire extinguisher is properly charged and serviced. Facility maintains an adequate supply of perishable and non-perishable foods. All required forms are posted. Medications are locked and centrally stored. Individual beds were observed. No firearms or weapons are allowed in the facility. Fence surrounding the pool is in compliance. There are no pets at the facility. LPA's reviewed client files and conducted staff. Client interviews were not conducted due to the client being non-verbal. Deficiencies were cited on todays visit, see LIC809-D. A copy of this report was left at the facility at the conclusion of inspection.

Deficiencies:
80019(e): Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility
84361(f): Documentation and Reporting Requirements

(f) The licensee must maintain a monthly log of each use of manual restraints. The log must include
80066(a): Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information
84066(b): Personnel Records

(b) The licensee shall maintain the following personnel records


summary: Facility Evaluation

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Narrative:
On the above date, Licensing Program Analysts (LPA's) Lidia Tinoco and Vanessa Galvan traveled to the Kids First Alborada Group Home for the purpose of conducting a POC visit to make sure all of the appropriate corrections were made. LPA's met with facility manager, Ernest Ratcliff. LPA's conducted a facility walk through and file review of staff and client files. LPA's confirmed that all of the corrections were made and gathered copies of pertinent documentation. No deficiencies were cited or observed on today's visit. A copy of this report was left at the facility with Ernest Ratcliff at the conclusion of the inspection.

met_with: Ernest Ratcliff


facility_name: KIDS TO KIDS - FAITH HOUSE

raw_content:
Investigation Findings:
13On 2/12/24, at 9:45 am, Licensing Program Analyst (LPA) Nestor Gomez made an unannounced inspection to the above facility for the purpose of concluding the investigation on the above allegations and deliver the findings. LPA spoke with Facility Manager, Madison Pennigton and together, discussed the investigative findings. During the investigative process by Licensing program Analyst (LPA), Nestor Gomez, all relevant parties have been accounted for and interviewed. During the confidential interviews, the validity of the allegations could not be determined. The parties interviewed either confirmed or denied the allegations. Staff/client accounts of the incident were conflicting. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies are being cited at this time. Exit Interview conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nestor Gomez 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: Madison Pennington - Facility Manager


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Investigation Findings:
13On August 26, 2025, at 12:14PM Licensing Program Analyst (LPA), Rosslyn Gray contacted the Licensee to conclude the complaint investigation. During the investigation, LPA Gray interviewed all available parties and reviewed documentary evidence. Confidential statements and an internal investigation determine that staff did not follow program protocol to prevent inappropriate behaviors between minors and resulting in a minor being sexually assaulted. Statements indicate that clients were not properly supervised, and there was no documentary evidence to support that 15-minute room checks were conducted. Due to the evidence obtained during the investigation, LPA determined that the allegation is substantiated, meaning that the preponderance of the evidence standard has been met. Per California Code of Regulations, Title Division Six, regulation 80078 (a): Responsibility for Providing Care and Supervision. Staff did not provide care and supervision that met the needs of clients in care. An exit interview was conducted, appeal rights provided, and a copy of this report was emailed to the Administrator, David Yasutake. SubstantiatedEstimated 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 31-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: KIDS TO KIDS - FAITH HOUSEFACILITY NUMBER: 565802328

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

met_with: Administrator, David Yasutake

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
On 5/24/23 at 10:00am, Licensing Program Analyst (LPA) Christine Wilson conducted an announced, prelicensing inspection. LPA Wilson met with the applicant, David Yasutake, Facility Manager Chris Thompson and Assistant Manager Xiomara Lopez. The proposed facility will provide care and supervision for 6 ambulatory only female children, ages 12 through 17 years old. The facility is one-story home which contains three (3) bedrooms, and two (2) bathrooms. The home has a fully equipped kitchen and a spacious living room and dining room, that can be utilized as a multipurpose room for homework and activities. The front yard, and side yard was observed to be secure with a cement fence 7ft in height , free of obstructions, and neat. The facility maintains one facility vehicle, Honda Odyssey not at the facility at the time of the inspection. There are (2) charged fire extinguishers through the facility, last inspected on 3/25/23. (1) Carbon monoxide and (5) smoke detectors were tested and fully functioning. Detergents and cleaning supplies were observed to be locked and inaccessible to minors. Medication closet located in staff office was observed to be secured and inaccessible to minors. Facility files will be maintained within the staff office. LPA observed the following during inspection: Living Room: the living room is a large open space that functions as a area for relaxation, with plenty of seating for 8+ people, a TV will be purchased, books and games are available and a functioning window is without a screen .There is a working smoke detector and a carbon monoxide detector in this space Dining Area: Has a table with seating for (4) as well a a bar with seating for (4) with cabinet space. Kitchen: equipped with a stove (2) burners, microwave, oven, refrigerator, plenty of cabinet space, and enough plates/cups/utensils for all clients. Trash cans are covered. Dishwashing machine is in working order and will not be used. Hallway: The hallway has a (1) linen closet and maintains enough linen and towels for all residents. There is a working smoke detector in this space. (Continued on 809C) Bedroom #1: Is adjacent to the living room, will be occupied by two clients with two twin size beds, dressed with clean linens, on each side of the room. There are adequate closets and (2) drawers (2). The bedroom does not serve as a passageway to any other part of the facility. Bedroom #2: will be occupied by two clients with two twin size beds, dressed with clean linens, on each side of the room. There are adequate closets (2)and (2) drawers. There is a functioning smoke alarm. The bedroom does not serve as a passageway to any other part of the facility. Bedroom #3 :will be occupied by two clients and maintain two twin beds, There is adequate closet (1) and (2) drawers. There is a functioning smoke alarm.. There is no window screen. Bathrooms- there are two (2) bathrooms throughout the facility, each with operational plumbing and running water that meets temperature requirements. Peach bathroom is shared with Bedroom 3 and staff. Blue bathroom is used for Bedrooms 1&2. Outdoor Space- the outdoor space has concrete. The Licensee communicates that it will be used " for clients to come outside and paint" There is a gazebo structure, with an empty, non-functioning covered spa. Laundry: located in the driveway area in a open shed and equipped with a washer and dryer in working order, Laundry detergents and cleaning supplies are kept in locked hallway closet and are inaccessible to clients without supervision. Backyard - there is an enclosed cement fence that extends around the perimeter of the facility that meets height requirements. There is no body of water on the premises. The front and side of the facility appeared clean and orderly with no hazards. Medication station- medications will be stored in a locked cabinet, in a closet in the staff office. The policy for medication administration will be posted on the inside of the door and was reviewed by LPA. Medication boxes were kept locked within the locked cabinet, with a standard key lock. Staff office- this office is located near the driveway and has laptops, a desk, and chairs. This space will be utilized for staff to conduct administrative duties, and where client records will be stored. LPA observed that door does lock. This area also functions to hold locked storage space for sharps, cleaning supplies, hygiene supplies and extra bathroom linen. There is no additional bathroom designated for staff. Licensee indicates that Bathroom #2 will be used by staff and clients. An exit interview was conducted, and a copy of this report was discussed emailed to the licensee.

met_with: Facility Administrator