facility_name: CENTER FOR POSITIVE CHANGES

raw_content:
Narrative:
...CONTINUED Confidential interviews indicate that although C2 did chase and strike C1 with a rock while staff were present, one staff member (S2) was attempting to de-escalate C2 and keep the clients separate by having each client go in a different room just before the assault occurred. A record review of the program statement reveals that staff at the facility are unable to use physical restraint as a means of intervention. Therefore, the staff did not use any restraint but attempted to de-escalate the altercation between C1 and C2 by separating them and having them in two rooms supervised by S2; at the same time, the S1 went downstairs to call law enforcement. Based on confidential interviews and record review, the allegation that Staff (S1-S2) did not prevent a minor (C2) from causing injury to another minor (C1) in care is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of the report was provided along with appeal rights to D'Andre James, Facility Manager.

Investigation Findings:
13On February 23, 2024, at 3: PM, Licensing Program Analyst (LPA) Jacob Salem met with D'Andre James, Facility Manager of the Center for Positive Changes to deliver the findings for the above-stated allegation. LPA Salem interviewed Staff (S1-4) and Clients (C1 & C3). C2 was not interviewed due to declining to speak with LPA Salem. In addition, LPA Salem reviewed C1-C2's Needs and Services Plans and Statement of Dangerous Propensities, the facility's Program Statement, and Special Incident Reports. On November 1, 2023, Community Care Licensing (CCL) received an allegation that Staff (S1-S2) did not prevent a minor (C2) from causing injury to another minor (C1) in care. Specifically, it was reported that a C2 chased and hit C1 in the head with a rock while under staff supervision. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Jacob Salem 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Center for Positive Changesfacility Number: Visit Date: 02/23/ 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...CONTINUED Confidential interviews indicate that although C2 did chase and strike C1 with a rock while staff were present, one staff member (S2) was attempting to de-escalate C2 and keep the clients separate by having each client go in a different room just before the assault occurred. A record review of the program statement reveals that staff at the facility are unable to use physical restraint as a means of intervention. Therefore, the staff did not use any restraint but attempted to de-escalate the altercation between C1 and C2 by separating them and having them in two rooms supervised by S2; at the same time, the S1 went downstairs to call law enforcement. Based on confidential interviews and record review, the allegation that Staff (S1-S2) did not prevent a minor (C2) from causing injury to another minor (C1) in care is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of the report was provided along with appeal rights to D'Andre James, Facility Manager. SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of 2

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0

met_with: D'Andre James, Facility Manager


state: CA

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
According to confidential interviews, staff also offered incentives and options to prevent C1 from absconding from the facility. Regarding C1's substance abuse, confidential interviews stated that facility staff would conduct checks in client's pockets, clothing and bags whenever client would return from AWOL (absence without official leave) or home passes, as well as conduct perimeter checks on the property and confiscate any contraband found. While other confidential Information received by Licensing Office stated that these allegations had occurred. Based on interviews and confidential information obtained during the course of this investigation, the allegations that Facility Staff did not follow Child # 1's (C1) intervention plans to ensure that minor attended school, did not abscond from facility, as well as address C1's substance abuse while in care, may have occurred, however is not supported or proven by evidence. Therefore, the above allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided.

Investigation Findings:
13Licensing Program Analyst (LPA), Daniel Mena met with Facility Manager, D'andre James to discuss the investigative findings for the above stated allegations. Licensing Program Analysts (LPAs), Lucero Jauregui and Daniel Mena conducted inspections to the Short Term Residential Therapeutic Program (STRTP). No immediate hazards observed. The investigation was jointly conducted by LPAs Jauregui and Mena. LPAs Jauregui and Mena interviewed Facility Director (FD), four staff (Staff #1 (S1), Staff #2 (S2), Staff #3 (S3) & Staff # 4 (S4), two clients (Child # 1 (C1) & Child # 2 (C2), as well as reviewed client and facility records. Community Care Licensing received information on May 30, 2023, alleging that Facility Staff did not follow Child # 1's (C1) intervention plans to ensure that minor attended school, did not abscond from facility, as well as address C1's substance abuse while in care. Information obtained in confidential interviews did not corroborate the allegations with a preponderance of evidence. LPAs Jauregui and Mena obtained conflicting information during interviews. Confidential interviews denied allegations that staff failed to address C1's school attendance, absconding and substance abuse. According to confidential interviews, facility staff would encourage C1 to attend school every day by trying to prepare C1 for school with enough time, by counseling C1 on the importance of education, as well as by offering C1 incentives. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Daniel Mena 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: CENTER FOR POSITIVE CHANGESFACILITY NUMBER: VISIT DATE: 05/10/2024

report_type: Complaint Investigation

met_with: D'andre James

complaint_status: unsubstantiated


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
...CONTINUED Confidential interviews indicated that S1 does not handle other clients in care in a rough manner. CCL also received the allegation that Staff (unnamed) are not addressing pests at the facility. It was reported there were cockroaches in the kitchen and staff were not addressing it. Confidential interviews indicated that cockroaches and other bugs were frequently seen in the facility kitchen, as well as in client bedrooms. Conflicting confidential interviews indicated that cockroaches were rarely seen at the facility, and the client who had cockroaches in their rooms required redirection with throwing away food. Confidential interviews indicated that staff have the kitchen treated for pests when cockroaches are seen. Confidential interviews and observations indicated that staff maintain the home to be clean and sanitary. CCL also received the allegation that Staff (S1) did not safeguard a resident's (C1) personal belonging. It was reported that S1 threw C1's phone after C1 placed their phone on S1's car. Confidential interviews indicated that S1 threw C1's phone on the pavement because of C1 tossing their phone on the hood of S1's car, and as a result C1's phone was damaged. A conflicting confidential interview indicated that S1 picked up and placed the phone on the front porch stairs leading to C1 becoming agitated. Confidential interviews indicated that C1 was later seen using their phone despite complaining about the phone being broken. CCL also received the allegation that Staff (S1) spoke inappropriately to a resident (C1). It was reported that S1 accused C1 of taking a knife out of the kitchen but then later found the missing knife in the kitchen. Confidential interviews indicated that S5, not S1, was the staff searching for the knife. Confidential interviews indicated that S5 told C1 they "know [C1] took the knife" and did not ask any other clients, despite C1 not taking things like that previously. Conflicting confidential interviews indicated that S5 brought all the clients into the game room to question them about the missing knife, as well as conduct a search of multiple clients' rooms. A confidential interview indicated that C1 was asked about the knife first due to C1 suspiciously teasing the staff while they were searching in the kitchen; however, other clients were asked as well. Confidential interviews indicated that the knife was eventually found in a location the staff previously searched. Continued... ...CONTINUED Based on conflicting confidential interviews and observations, the allegations that staff handled a resident in a rough manner, staff are not addressing pests at the facility, staff did not safeguard a resident's personal belonging, and staff spoke inappropriately to a resident are unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted, and a signed copy of this report and appeal rights were provided to Amber Carter, Facility Manager.

Investigation Findings:
13On January 10, 2025, at 10: AM, Licensing Program Analyst (LPA) Jacob Salem met with Amber Carter, Facility Manager of Center for Positive Changes to deliver the finding for the above-stated allegations. LPA Salem initiated a complaint inspection at the facility on 7/05/24 at 1: PM and no immediate deficiencies were observed. During the investigation, LPA Salem interviewed Clients (C1-C6) and Staff (S1-S5). LPA Salem obtained and reviewed pertinent records. On June 28, 2024, Community Care Licensing (CCL) received an allegation that Staff (S1) handled a resident (C1) in a rough manner. It was reported that C1 entered the office to obtain a snack and S1 grabbed and pushed C1. A confidential interview indicated that S1 pushed C1 and pulled C1 out of the office by C1's wrist; however, there were no third-party witnesses to this incident. A conflicting confidential interview indicated that C1 was verbally redirected to ask for permission before grabbing snacks, and as a result C1 threw S1's property on the ground before storming out of the office. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Center for Positive Changesfacility Number: Visit Date: 01/10/ 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...CONTINUED Confidential interviews indicated that S1 does not handle other clients in care in a rough manner. CCL also received the allegation that Staff (unnamed) are not addressing pests at the facility. It was reported there were cockroaches in the kitchen and staff were not addressing it. Confidential interviews indicated that cockroaches and other bugs were frequently seen in the facility kitchen, as well as in client bedrooms. Conflicting confidential interviews indicated that cockroaches were rarely seen at the facility, and the client who had cockroaches in their rooms required redirection with throwing away food. Confidential interviews indicated that staff have the kitchen treated for pests when cockroaches are seen. Confidential interviews and observations indicated that staff maintain the home to be clean and sanitary. CCL also received the allegation that Staff (S1) did not safeguard a resident's (C1) personal belonging. It was reported that S1 threw C1's phone after C1 placed their phone on S1's car. Confidential interviews indicated that S1 threw C1's phone on the pavement because of C1 tossing their phone on the hood of S1's car, and as a result C1's phone was damaged. A conflicting confidential interview indicated that S1 picked up and placed the phone on the front porch stairs leading to C1 becoming agitated. Confidential interviews indicated that C1 was later seen using their phone despite complaining about the phone being broken. CCL also received the allegation that Staff (S1) spoke inappropriately to a resident (C1). It was reported that S1 accused C1 of taking a knife out of the kitchen but then later found the missing knife in the kitchen. Confidential interviews indicated that S5, not S1, was the staff searching for the knife. Confidential interviews indicated that S5 told C1 they "know [C1] took the knife" and did not ask any other clients, despite C1 not taking things like that previously. Conflicting confidential interviews indicated that S5 brought all the clients into the game room to question them about the missing knife, as well as conduct a search of multiple clients' rooms. A confidential interview indicated that C1 was asked about the knife first due to C1 suspiciously teasing the staff while they were searching in the kitchen; however, other clients were asked as well. Confidential interviews indicated that the knife was eventually found in a location the staff previously searched. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Center for Positive Changesfacility Number: Visit Date: 01/10/ 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...CONTINUED Based on conflicting confidential interviews and observations, the allegations that staff handled a resident in a rough manner, staff are not addressing pests at the facility, staff did not safeguard a resident's personal belonging, and staff spoke inappropriately to a resident are unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted, and a signed copy of this report and appeal rights were provided to Amber Carter, Facility Manager. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 3 of 5

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0

met_with: Amber Carter, Facility Manager


raw_content:
Narrative:
...CONTINUED Confidential interviews indicated that staff assist clients with looking for things that are missing, encourage clients not to loan each other things, hold on to expensive items for clients, and if there is a legitimate concern of clients having their money stolen, staff will recompensate clients or have current clients pay each other back. CCL also received the allegations that a staff member (S3) brandished a weapon in the presence of minor(s) (C1) in care, and that the licensee is not ensuring that residents are provided a safe environment while in care. It was reported that S3 pulled a knife to C1's side after C1 told S3 to "shut up," and that S3 continued to work in the facility after this was reported. A confidential interview indicated that S3 put a kitchen knife "pretty close" to C1's side after C1 used profanity toward S3 while helping in the kitchen; however, there were no third-party witnesses to this incident. A conflicting confidential interview indicated that C1 never became hostile or used profanity toward S3 while helping S3 in the kitchen. Confidential interviews indicted that S3 has not done anything to make other clients in care feel uncomfortable, and that other clients in care feel safe in the home. Confidential interviews indicated that S3 continued to work at the facility occasionally when assistance was needed but was moved to another of the company's facilities soon after the allegation was made regarding C1. CCL also received the allegation that a staff (S3) member antagonized minor (C1) in care. It was reported that S3 laughs at and makes sexualized comments to C1 when C1 is in the bathroom. Confidential interviews indicated that S1 and S4 would conduct safety checks when C1 locked themselves in the bathroom for an extended period and was not responding to staff asking if C1 was OK. Confidential interviews indicated that S1, not S3, made a sexualized comment to C1 when C1 refused to exit the bathroom. Conflicting confidential interviews indicated that S1 did not make sexualized comments to C1 but may have made a comment that was misinterpreted as inappropriate. Confidential interviews indicated that other clients in care have not been made to feel uncomfortable by S1. Continued... ...CONTINUED Based on conflicting confidential interviews and records reviewed, the allegations that staff are not safeguarding minor in care's belongings, staff member brandished a weapon in the presence of minor(s) in care, licensee is not ensuring that residents are provided a safe environment while in care, and staff member antagonized minor in care are unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted, and a signed copy of this report and appeal rights were provided to Amber Carter, Facility Manager.

Investigation Findings:
13On January 10, 2025, at 10: AM, Licensing Program Analyst (LPA) Jacob Salem met with Amber Carter, Facility Manager of Center for Positive Changes to deliver the findings for the above-stated allegations. LPA Salem initiated a complaint inspection at the facility on 7/05/24 at 2: PM and no immediate deficiencies were observed. During the investigation, LPA Salem interviewed Clients (C1-C5) and Staff (S1-S5). LPA Salem obtained and reviewed pertinent records. On July 3, 2024, Community Care Licensing (CCL) received an allegation that Staff (unnamed) are not safeguarding minor (C1) in care's belongings. It was reported that C1 had their things stolen by C1's roommate. A confidential interview indicated that C1 had money and electronics taken by other clients, and that staff "do not care" or try to prevent clients from stealing from each other. A conflicting confidential interview and record review indicated that C1 was recompensated for the money taken by another client, and that C1 would frequently loan out their items and money before claiming they were stolen. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Center for Positive Changesfacility Number: Visit Date: 01/10/ 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...CONTINUED Confidential interviews indicated that staff assist clients with looking for things that are missing, encourage clients not to loan each other things, hold on to expensive items for clients, and if there is a legitimate concern of clients having their money stolen, staff will recompensate clients or have current clients pay each other back. CCL also received the allegations that a staff member (S3) brandished a weapon in the presence of minor(s) (C1) in care, and that the licensee is not ensuring that residents are provided a safe environment while in care. It was reported that S3 pulled a knife to C1's side after C1 told S3 to "shut up," and that S3 continued to work in the facility after this was reported. A confidential interview indicated that S3 put a kitchen knife "pretty close" to C1's side after C1 used profanity toward S3 while helping in the kitchen; however, there were no third-party witnesses to this incident. A conflicting confidential interview indicated that C1 never became hostile or used profanity toward S3 while helping S3 in the kitchen. Confidential interviews indicted that S3 has not done anything to make other clients in care feel uncomfortable, and that other clients in care feel safe in the home. Confidential interviews indicated that S3 continued to work at the facility occasionally when assistance was needed but was moved to another of the company's facilities soon after the allegation was made regarding C1. CCL also received the allegation that a staff (S3) member antagonized minor (C1) in care. It was reported that S3 laughs at and makes sexualized comments to C1 when C1 is in the bathroom. Confidential interviews indicated that S1 and S4 would conduct safety checks when C1 locked themselves in the bathroom for an extended period and was not responding to staff asking if C1 was OK. Confidential interviews indicated that S1, not S3, made a sexualized comment to C1 when C1 refused to exit the bathroom. Conflicting confidential interviews indicated that S1 did not make sexualized comments to C1 but may have made a comment that was misinterpreted as inappropriate. Confidential interviews indicated that other clients in care have not been made to feel uncomfortable by S1. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Center for Positive Changesfacility Number: Visit Date: 01/10/ 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...CONTINUED Based on conflicting confidential interviews and records reviewed, the allegations that staff are not safeguarding minor in care's belongings, staff member brandished a weapon in the presence of minor(s) in care, licensee is not ensuring that residents are provided a safe environment while in care, and staff member antagonized minor in care are unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted, and a signed copy of this report and appeal rights were provided to Amber Carter, Facility Manager. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 3 of 3

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0


summary: Facility Evaluation

raw_content:
Narrative:
On 06/07/2021 at 9: A.M., Licensing Program Analyst (LPA) Marisol Lopez conducted a required annual inspection at the facility above. LPA met with Administrator Robyn Reyes who led the tour of Center for Positive Changes. LPA inspected the facility interior and exterior. There were six male clients residing at this facility. The facility is a two-story residence with three bedrooms, three bathrooms, two living rooms, one upstairs and one downstairs, a dining room, second floor den, kitchen, walk-through pantry area, upstairs hallway with two storage closets, first floor laundry room, 2 staff offices, therapy room and 2-car garage. The facility has been operating with a capacity of six males from ages 13 years old to 17 years old and non-minor dependents. Currently there are six children in care. Bedrooms are arranged so that no more than two children share a room and each bedroom includes adequate drawers and closet space for two children's belongings. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, and Personal Rights form. Medications are locked and centrally stored in a locked cabinet in the staff office. Licensee has provisions for contraceptives to be held in individually locked containers by clients. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client's bathroom was measured to be 117.0 degrees. Per facility staff, no firearms or weapons are allowed in the facility. Facility appears to be meeting the terms and conditions of their license. Licensee has obtained National Accreditation through CARF and the Accreditation is valid through August 2022. LPA discussed the following with the Administrator: Incident reporting, including incidents related to Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. Personnel Files are maintained off-site and transported to LPA within reasonable time. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. A review of client records was also completed on this date including the Medication Administration Record (See Confidential Name List- LIC 811 dated on June 07, 2021). Personnel files were reviewed to ensure they contained all required documentation. Children and staff records are organized. Staff's CPR and First Aid card were current. Child's records contain original needs and services plan signed by the child and their authorized rep. Child's records contain authorization for emergency medical care signed by each child's authorized rep. Licensee has a current needs and services plan for each resident on file. Facility personnel meet staff training requirements Administrator Robyn Reyes is present at the facility a minimum of 20 hours a week, as verified by staff schedule and interviews. Appropriate staff/client ratios were verified during this inspection. Based on observations made during the inspection, no deficiencies observed during today's visit. An exit interview was conducted and this report was reviewed with Administrator Robyn Reyes and a copy of this report was provided.

report_type: Facility Evaluation

visit_type: Annual

met_with: Robyn Reyes


summary: Facility Evaluation

raw_content:
Narrative:
On May 24, 2023, at 8: AM, Licensing Program Analyst (LPA) Gloria Meza-Gonzalez conducted an inspection at the facility above. LPA Meza-Gonzalez met with Program Manager (PM) Paul Kelley, Residential Director (RD) Robyn Reyes, and Facility Manager (FM) D'Andre James. The purpose of the inspection is to conduct a random annual inspection. The facility is licensed for six male youths with an age range of 14 to 17 years old as well as non-minor dependents. There are five youths in care. There were three youths present at the time of the inspection. LPA Meza-Gonzalez toured the facility with FM James. LPA Meza-Gonzalez inspected the facility's interior and exterior. The facility is a two-story residence with three bedrooms and three bathrooms. The first floor is set up as follows: The staff office, cleaning supply closet, laundry room, storage closet, garage, living room, bathroom, and bedroom. The medications and client files are kept in a locked cabinet in the locked staff office. The cleaning supplies are kept in a locked closet. The second closet has extra bedding and linen. The therapy office has two desks, two chairs, phones, and computers. The therapy office is locked when not in sure. Bedroom #1 has adequate drawers, closet space for two children's belongings, and two twin beds. One client per bed. The clients share the bathroom. The garage is a recreation area that has weights and a pool table for clients' use. There is also a deep freezer to store extra food. The second floor has two living rooms, a kitchen, a dining room, a closet with games, two bedrooms, two bathrooms, and two balconies. The two livings have two couches and two TVs. LPA Meza-Gonzalez observed the kitchen has two days of perishable and seven days of nonperishable foods. In the dining room, there is a table with six chairs. Bedroom #2 has adequate drawers, closet space for two children's belongings and two twin beds. One client per bed. The clients share the bathroom in the hallway. Bedroom #3 has adequate drawers, closet space for two children's belongings and two twin beds. One client per bed. The clients share the bathroom. There is a closet between Bedroom #2 and Bedroom #3 that has games for clients' use. See LIC809C page 2. LPA Meza-Gonzalez observed seven smoke detectors and carbon monoxide detectors in the facility. The smoke and carbon monoxide was tested and was observed to be in working order. The facility has two fire extinguishers. The two fire extinguishers are properly charged and serviced. Facility grounds are clean and free of debris and observable hazards. All required forms are posted including the Grievance Procedures, Visitation Policies, Menu, and Personal Rights. The hot water in the client's bathroom was measured to be 120.0 degrees. Per facility staff, no firearms or weapons are allowed in the facility. The facility appears to be meeting the terms and conditions of its license. Licensee has obtained National Accreditation through CARF and the Accreditation is valid through August 31, 2025. LPA Meza-Gonzalez discussed the following with RD Reyes and PM Kelley: Incident reporting, including incidents related to Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. Personnel Files are maintained off-site and transported to LPA Meza-Gonzalez within 30 minutes. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. A review of client records was also completed on this date including the Medication Administration Record (See Confidential Name List- LIC 811 dated May 24, 2023). Personnel files were reviewed to ensure they contained all required documentation. Children and staff records are organized. The staff's CPR and First Aid cards were current. The clients' records contain the original needs and services plan signed by the child and their authorized representative. The clients' records contain authorization for emergency medical care signed by each child's authorized representative. Licensee has a current needs and services plan for each resident on file. Facility personnel meets staff training requirements. Based on observations made during the inspection, no deficiencies were observed during today's visit. An exit interview was conducted and this report was reviewed with RD Reyes and a copy of this report was provided.

met_with: Paul Kelley and Robin Reyes


summary: Facility Evaluation

raw_content:
Narrative:
On August 15, 2025 at 10: AM, Licensing Program Analyst (LPA) Jacob Salem conducted an announced visit to the above facility and met with Amber Carter, Facility Manager for the purpose of conducting an annual inspection. LPA reviewed five client files (C1-C5), which are kept locked in the staff office. The client files reviewed contained the required information and records, including pre-placement screenings, personal rights and facility policy acknowledgements, and medication logs. LPA inspected the facility's physical plant, including personal rights postings, health related services, buildings and grounds, food services, indoor and outdoor activity space, and furniture, fixtures, equipment and supplies. The home is clean, in good repair, and free from observable risks to clients' health, safety, and personal rights. The home is a two story building with three client bedrooms and three client bathrooms which are set up as follows: Bedroom #1 downstairs has two twin beds and currently sleeps two clients, bedroom #2 has two twin beds and currently sleeps one client, and bedroom #3 has two twin beds and currently sleeps two clients. There is a kitchen, two living rooms living room, staff office and storage closets, therapy office, and backyard/patio. LPA conducted two staff interviews. Due to time constraints, the annual is being extended to conduct a review of staff files and interview clients. An exit interview was conducted and a signed copy of this report was provided to Amber Carter, Facility Manager.


summary: Facility Evaluation

raw_content:
Narrative:
On August 18, 2025 at 9: AM, Licensing Program Analyst (LPA) Jacob Salem conducted an announced visit to the above facility and met with Amber Carter, Facility Manager. The purpose of this Case Management inspection is to conduct an annual continuation from 8/15/2025. LPA reviewed five staff files (S1-S5), at the facility's corporate office. The staff files reviewed contained the required information and records, including the required clearances and health screenings, hiring paperwork and qualifications, and on-boarding trainings. LPA conducted two client interviews at the facility. Based on observations made during the inspection, there were no deficiencies cited at this time. An exit interview was conducted with Amber Carter, Facility Manager and a signed copy of this report was provided.

visit_type: Case Management


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews reported that even though the facility staff say they tried to wake up and encourage C1 to go to school; this actually did not happen. Other confidential interviews reported that the facility staff do routinely wake up the clients and instruct them to get ready for school. Confidential interviews reported that C1 sets their alarm to wake up in the morning but sometimes C1's roommate turns off the alarm before it goes off. In regard to the allegation that staff (S2) threatened a minor (C1) while in care; it was reported that S2 told the C1 that C1 "had something waiting for C1." It was further reported that it was unknown exactly what that meant, if it was a threat or something else. Confidential interviews reported that S2 has verbally threatened C1 and other clients at the facility. Other confidential interviews reported that S2 did not verbally threaten C1 or any other clients at the facility.. Confidential interviews reported that some clients did not remember ever receiving a verbal threat from S2, such as the one described in the LIC 802 narrative In regard to the allegation that staff (names not provided) mishandle a minor's (C1) personal items; it was reported that the staff (names not provided) search C1's room and leave it messy when C1 comes back from their family visit. Confidential interviews reported that when C1 returned from a family visit, it appeared C1's belongings were not in their original spot, of where they initially left it. Confidential interviews reported that none of C1's belongings were damaged, but they were misplaced. Confidential interviews reported that staff only search clients room if there is a reasonable suspicion that contraband is present. Confidential interviews reported that facility staff believe that C1's roommate moved around their possessions. Confidential interviews reported that staff usually leave a client's room in the stated it was prior to the search. In regard to the allegation that staff did not prevent the minors (C2, C3, C4, C5) from causing harm to another minor; it was reported that C1 was slapped by another youth in the facility (C2) and that C1 was "jumped" by two other youths (names not provided). Confidential interviews reported that C1 was slapped by C2, and in a separate incident, C1 was attacked by two other youths. Confidential interviews reported that the names of these two other attackers were not provided. Confidential interviews reported that an incident involving a two-on-one physical attack on C1 was not witnessed by facility staff. Other confidential interviews reported that staff supervised the clients at all times and that acts of physical aggression were addressed and reported. Continued on the next page In regard to the allegation that staff (S1) behavior poses as a risk to a minor (C1); it was reported that while S2 was transporting C1 back to the facility; they stopped in a "shady part of town." It was further reported that S2 exchanged notes and/or money with a community member. Confidential interviews reported that S2 was handling personal business while on duty, and that C1 was in the vehicle while this was happening. Confidential interviews reported that S2 admitted that on one occasion, S2 met their landlord at a meeting spot, on the way to the facility, to pay their rent. Confidential interviews reported that this was only a one time occurrence. In regard to the allegation that staff (names not provided) do not ensure a minor (C1) is taking their medication; it was reported that C1 is not getting their medication from the facility. Confidential interviews reported that the facility forgot to provide C1 their medication on multiple occasions, but documented it as a refusal on C1's part. Confidential interviews reported that C1 has admitted to refusing their medication on more than occasion, but that C1 denied refusing their medication for as many times as the facility has stated. Other confidential interviews reported that the facility follows their protocol and offer each client their medications on a regular basis and document the process on each clients' medication log. Confidential interviews reported C1's medication log was collected and that it appeared that each instance of acceptance/refusal was inputted correctly. Based on confidential interviews and record reviews, the allegations that staff do not ensure a minor is attending school regularly, staff threatened a minor while in care, staff mishandle a minor's personal items, staff did not prevent the minors from causing harm to another minor, staff behavior poses as a risk to a minor and staff do not ensure a minor is taking their medication; may have occurred, however, there was not a preponderance of evidence to support the alleged violations. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report and appeal rights were explained and given to Administrator D'Andre James.

Investigation Findings:
13On 12/4/2025, at 09: AM, Licensing Program Analyst (LPA) Joon Choi conducted an unannounced visit at Center for Positive Changes # Short Term Residential Treatment Program (STRTP) and met with Administrator De'Andre James to deliver the investigative finding for the allegations listed above. On 05/27/2025, Community Care Licensing received allegations that staff do not ensure a minor is attending school regularly, staff threatened a minor while in care, staff mishandle a minor's personal items, staff did not prevent the minors from causing harm to another minor, staff behavior poses as a risk to a minor and staff do not ensure a minor is taking their medication. On 06/05/2025, LPA Jacob Salem arrived at the facility, conducted a health and safety inspection, and obtained pertinent documents. No immediate health and safety hazards were observed. In addition, LPA Salem interviewed client C1), staff 1 and 2 (S1, S2), and the County Social Worker (CSW). LPA Choi interviewed client 3 and 4 (C3, C4). In regard to the allegation that staff (names not provided) do not ensure a minor (C1) is attending school regularly; it was reported that "C1 is not attending school..." CONTINUED ON THE NEXT PAGE UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Joon R Choi 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: CENTER FOR POSITIVE CHANGESFACILITY NUMBER: VISIT DATE: 12/04/2025

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

met_with: D'Andre James, Administrator


raw_content:
Investigation Findings:
13On December 5, 2025, at 9: AM, Licensing Program Analyst's (LPAs) Reyna Martinez and Melissa Renovato met with Amber Carter, Facility Manager of Center for Positive Changes (CFPC) to deliver the finding for the above-stated allegation. LPA Jacob Salem initiated a complaint inspection at the facility on April 7, 2025 at 9: AM, and no immediate deficiencies were observed. During the investigation, LPA Salem interviewed Clients (C1-C6) and Staff (S1-S3). Pertinent records were obtained and reviewed. LPA Martinez interviewed Complainant, Clients (C1, C4, C7-C9), County Social Worker, and Staff (S4). On March 28, 2025, Community Care Licensing (CCL) received the allegation that Staff (S2) spoke inappropriately to Client (C1) in care. It was reported that S2 open C1s bedroom door and makes sexualized comments towards C1. C1 stated that S2 became verbally aggressive and argumentative during a confrontation. Allegedly, S2 did not back down or do anything to step away/diffuse the situation. Confidential interviews and records reviewed indicated that C1 has a history of aggressive behaviors towards others. Records reviewed indicated that CFPC had two complaints with similar allegations that involved S2 which were found to be Unsubstantiated. Conflicting confidential interviews indicated that S2 made sexualized comments toward C1. Confidential interviews indicated that other clients in care have not been made to feel uncomfortable or been spoken to inappropriately by S2. LPA received inconsistent information regarding the allegation. Based on confidential interviews, records reviewed, and observations, the allegation that Staff spoke inappropriately to client in care is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted with Amber Carter, Facility Manager and a copy of this report was provided to the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Reyna Martinez 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: 0

met_with: Amber Carter


raw_content:
Narrative:
Continued from LIC 9099.. Based inconsistencies in the confidential interviews, on the allegation of Staff are not providing adequate care and supervision resulting in children destroying property, on the allegation of Staff do not prevent children from smoking on the premises, and on the allegation of Facility does not have a full-time therapist to meet the needs of children in care are found to be unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Amber Carter, Facility Manager and a copy of this report and appeal rights were provided.

Investigation Findings:
13On December 5, 2025, at 9: AM, Licensing Program Analyst's (LPAs) Reyna Martinez and Melissa Renovato met with Amber Carter, Facility Manger of Center for Positive Changes (CFPC) to deliver the findings for the above-stated allegations. LPA Jacob Salem initiated a complaint inspection at the facility on June 30, 2025 at 10: AM, and no immediate deficiencies were observed. During the investigation, LPA Salem interviewed Staff (S1 and S5), Reporting Pary (RP), and County Social Worker (CSW). LPA Martinez interviewed Reporting Pary (RP), County Social Worker #2 (CSW2), Clients (C1, C5, C7-C9), and Staff (S3, S8 and S9). Pertinent records were obtained and reviewed. On June 27, 2025, Community Care Licensing (CCL) received a complaint with the allegations that Staff not providing adequate care and supervision resulting in children destroying property, Staff do not prevent children from smoking on the premises, and Facility does not have a full-time therapist to meet the needs of children in care. Continued on LIC 9099-C... UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Reyna Martinez 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: CENTER FOR POSITIVE CHANGESFACILITY NUMBER: VISIT DATE: 12/05/2025

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 0


raw_content:
Narrative:
LPA Kinder conducted 1 confidential interview on 08/11/22. LPA Carmona conducted 13 confidential interviews and attempted 3 between 09/02/22- 11/09/22. Based on interviews conducted during the investigation process the allegation staff left minor unsupervised in a car for extended periods of time cannot be substantiated because statements made during a confidential interview conducted on 11/01/22 did not corroborate with the statement made during a confidential interview conducted on 11/08/22. In addition, LPA Carmona attempted and was unable to interview 2 of the 3 clients placed during the time frame the complaint was made. The confidential interview on 11/01/22 was unable to identify staff member who had left a minor unsupervised in car for an extended period of time. The confidential interview on 11/01/22 was consistent with the transportation logs dated 08/15/22 which documented a dentist appointment where two clients were transported. The staff member who initialed the transportation log stated they do not remember details of the transportation on 08/15/22. LPA Carmona received documentation of the dentist appointment which makes the statement given on 11/01/22 inconsistent. Lastly, 1 confidential interview conducted on 11/01/22 disclosed a minor being left in a car and 9 confidential interviews conducted from 8/11/22-11/09/22 denied the allegation. 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 allegations are Unsubstantiated An exit interview was conducted. A copy of this report and the Appeal Rights were provided via e-mail to Administrator, Staci Exceus.

Investigation Findings:
13On 11/10/22 at 10:10 a.m. Licensing Program Analyst (LPA) Jacqueline Carmona conducted a complaint inspection to the above Short Term Residential Therapeutic Program (STRTP) and met with Administrator, Staci Exceus for the purpose of delivering findings. During the investigation, LPA Carmona reviewed the agency's file at the licensing office, including the complaint history, criminal background check, incident reports and facility personnel report summary. LPA Kinder obtained four minors needs and services plans, LIC500, LIC9020, Center for Positive Changes Therapeutic Level System, the facility Program Statement Section 3 on Transportation. LPA Carmona obtained outing receipts for the months of July 2022, August 2022, and September 2022. Transportation logs for facility vehicles for the months of July 2022, August 2022, and September 2022 and email verification of a dental appointment. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Jacqueline Carmona 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: CENTER FOR POSITIVE CHANGESFACILITY NUMBER: VISIT DATE: 11/10/2022

met_with: Administrator, Staci Exceus.


raw_content:
Narrative:
Based on interviews conducted during the investigation process on the above allegations cannot be substantiated because statements given in 8 of the 14 confidential interviews conducted from 12/02/22 - 2/23/23 corroborated that the staff in the facility properly supervise the clients in care. 3 of the 14 confidential interviews conducted from 12/19/22- 1/19/23 corroborated that staff spends their time in the administrative office and is not properly supervising clients in the facility. In addition, the allegation reporting requirement cannot be substantiated because the administrator denied the allegation and stated they were having internet issues. 7 confidential interviews conducted from 12/08/22-2/23/23 corroborated the facility staff reports all incidents to CCL. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted. A copy of this report and the Appeal Rights were provided to the Agency Director .

Investigation Findings:
13On 2/28/23 at approximately 1:40 p.m. Licensing Program Analyst (LPA) Jacqueline Carmona conducted a complaint inspection to the above Short Term Residential Therapeutic Program (STRTP) and met with Agency Director Shavonne Powell for the purpose of delivering findings. During the investigation, LPA Carmona reviewed the agency's file at the licensing office, including the complaint history, criminal background check, incident reports dated 11/23/22 and 11/17/22, LIC500, LIC9020, SCAR report dated 11/17/22, email dated 12/08/22, case notes for two clients from August 2022 through December 2022. In addition, LPA Carmona reviewed two minors needs and services plans dated 12/21/22 and 10/11/22 and a CFT meeting sign in document dated 12/21/22. LPA Carmona conducted 14 interviews from 12/01/22- 2/23/23 and 1 attempted interview on 1/19/23. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Jacqueline Carmona 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: CENTER FOR POSITIVE CHANGESFACILITY NUMBER: VISIT DATE: 02/28/2023

met_with: Shavonne Powell, Agency Director


raw_content:
Narrative:
minor was not provided with school supplies is substantiated because statements given during 4 confidential interviews confirmed that the facility did not provide a client with school supplies. In addition, documentation was obtained which corroborated that minor was not provided with school supplies. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, ILS 87088 (i), are being cited on the attached LIC 9099D.") An exit interview was conducted. A copy of this report and the Appeal Rights were provided to the Administrator. Based on interviews conducted during the investigation process the allegations above cannot be substantiated because there were conflicting statements given in the 17 confidential interviews conducted from 1/19/23- 4/10/23. Incident reports reviewed by LPA Carmona from 10/08/22-12/21/22 also conflicted with statements given during the confidential interviews conducted. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted. A copy of this report and the Appeal Rights were provided to the Administrator.

Investigation Findings:
13On 4/21/23 at approximately 10:52 a.m. Licensing Program Analyst (LPA) Jacqueline Carmona conducted a complaint inspection to the above Short Term Residential Therapeutic Program (STRTP) and met with Administrator, Staci Exceus for the purpose of delivering findings. During the investigation, LPA Carmona reviewed the agency's file at the licensing office, including the complaint history, criminal background check, case notes dated December 2022, daily safety check form, and daily communication logs for the months of December 2022 and January 2023. In addition, LPA Carmona reviewed incident reports dated 10/08/22-12/21/22, needs and services plans dated 12/21/22 and 1/17/23, email dated 2/10/23. LPA Carmona conducted 17 interviews from 1/19/23- 4/10/23 and 2 attempted interviews on 1/19/23 and 2/21/23. Based on interviews conducted and documents obtained during the investigation process the allegation SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Jacqueline Carmona 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: CENTER FOR POSITIVE CHANGESFACILITY NUMBER: VISIT DATE: 04/21/2023

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

met_with: Staci Exceus, Administrator


raw_content:
Narrative:
Based on interviews conducted during the investigation process the allegations above cannot be substantiated because there were conflicting statements given in the 11 confidential interviews conducted from 1/26/23 - 4/04/23. In addition, documents obtained by LPA Carmona and client's personal property and valuables (LIC 621) conflicts with the statements made during 4 confidential interviews conducted on 2/02/23 and 4/04/23. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted. A copy of this report and the Appeal Rights were provided to the Administrator.

Investigation Findings:
13On 4/23/ at approximately 10:52 a.m.Licensing Program Analyst (LPA) Jacqueline Carmona conducted a complaint inspection to the above Short Term Residential Therapeutic Program (STRTP) and met with Administrator, Staci Exceus for the purpose of delivering findings. During the investigation, LPA Carmona reviewed the agency's file at the licensing office, including the complaint history, criminal background check, incident report dated 1/30/23, an email dated 1/31/23. In addition, LPA Carmona reviewed client's needs and services plan dated 12/21/22 and personal property and valuables (LIC621). LPA Carmona conducted 11 interviews from 1/26/23- 4/04/23 and 3 attempted interviews on from 2/21/23-2/28/23. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Jacqueline Carmona 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 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: CENTER FOR POSITIVE CHANGESFACILITY NUMBER: VISIT DATE: 04/21/2023


summary: Facility Evaluation

raw_content:
Narrative:
On 5/24/2021 at 8:50am Licensing Program Analyst (LPA) N. Sanders arrived at the above facility for the purpose of conducting a pre licensing inspection. LPA met with Stacy Exceys, facility Administrator and inspected the facility inside and out. The facility has a provisional license for six clients. There are four clients in care right now. The facility is clean and free of clutter. Kitchen is clean, sanitary and in good repair. Knives, sharp objects and cleaning supplies are locked. Facility has adequate amount of cooking and dishware supplies. Menu is posted. Water temperature measures 98F. Dining area has enough space for capacity. There are two days of perishable and seven days of non-perishable food. Additional fridge is located in the garage with more food supplies. Living room has a seating capacity for clients and staff. Furniture is in good repair. Activity area has age appropriate activities for population served. Floors are clean and in good repair. Windows have screens and blinds. There are four bedrooms in this facility. At this time there is one client for each bedroom. All bedrooms are specious enough to walk through and accommodates the required bedroom furniture. Each bedroom has lamps, a dresser and a closet space. Beds are in good repair, with good springs, clean mattresses, pillows, fitted sheets, flat sheets and blankets. Windows have screens and blinds. There are four bathrooms in this facility. Carbon monoxide detectors and smoke detectors meet standards. Fire extinguishers are up to date. Facility has enough supplies for linen, towels and a working phone for clients to make calls. Facility has a van and a car for transportation. Both vehicles were inspected and are in working condition. Both vehicles are insured and has renewed registration. Documents are in the car. Medications are located in staff room alongside with client files. Staff files are located in corporate office located in Sacramento, CA. Staff room is inaccessible to clients. First Aid Kit is complete. Medications are stored separately from toxins. Medication administration records being used. License, Foster Youth Personal Rights, Facility Sketch are posted in the entry room. There are cameras installed in common areas. The backyard is small and free of clutter. There are some chairs and a BBQ grill in the backyard. There are no bodies of water in this facility. LPA reviewed four clients files. Files have all required documents in them: Personal Rights signed by clients, Admission agreement, Medical Assessment, Appraisal and Needs and Services Plans, Safeguards and Cash Resources Information. Consent forms are signed and dated. Facility employees 15 staff including administrator and on call staff. LPA reviewed five staff files. Staff files have : First Aid Training Records, Training Records show required training hours for each staff, Criminal Records Statement and Clearances, Personal information alongside with Job Application, Medical History and TB test, Education Verification documents and signed Employee Rights. No title 22 regulations were cited on today's visit. A copy of this report was left with Stacy Exceys, Administrator.

met_with: Stacy Exceys, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 7/21/ Licensing Program Analyst (LPA) N. Sanders contacted the above facility to conduct virtual case management/incident report. Case management was generated from an incident report received by Sacramento Regional Office on 7/16/2021. LPA and facility representatives discussed one particular incident as well as clients running away frequently from the facility. It was discussed what can the facility do to support clients and avoid run-away behavior. Interviews were conducted. No citations were issued during today's visit. A copy of this report was emailed to Staci Exceus, Facility Administrator.

met_with: Staci Exceus, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 7/27/2021 at 11:45am Licensing Program Analyst (LPA) N. Sanders arrived at the above facility for the purpose of conducting case management/incident report. LPA met with Renee Robinson, Assistant Manager and discussed the incident. Sacramento Regional Office (RO) received an incident report on 7/26/2021 stating one client not having the inhaler. Client ended up in the hospital and was released the same day to facility staff. Inhaler and other medications were prescribed and given to facility staff. LPA reviewed client's file. Interviews with staff and client were conducted. Advisory Note (AN) was given to the facility. No title 22 regulations were cited on today's visit. A copy of this report was emailed to Staci Exceus.

met_with: Renee Robinson, Assistant Manager


summary: Facility Evaluation

raw_content:
Narrative:
On October 12, 2021 at 10:30 am Licensing Program Analyst (LPA), Yuvi Diaz made an unannounced visit to conduct a case management regarding an incident report received by The Department on 10/06/21 regarding Lack of Supervision. LPA met with Trayvon Kennedy, Facility Manager (who assisted with the inspection). STRTP is a two story home it consists of two living spaces, one dinning room, one kitchen, four bedrooms, 2.5 bathrooms, laundry room, and large office room for therapist and rehabilitation specialist. LPA conducted interviews with facility manager, one staff member, one client decline to interview, and gathered information about the former staff members. Documentation gathered: NSP Staff Roster Cient Face sheet Client Roster An exit interview was conducted at 12:15 pm with Trayvon Kennedy and a copy of this report will be emailed to Administrator Staci Exceus This case management investigation needs further investigation.

met_with: Trayvon Kennedy


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tina Rivera and Licensing Program Manager (LPM) Rosa Rodriguez made an unannounced annual inspection on 2/10/2022 at 8: AM. During the inspection LPA met with Staci Exceus, Administrator who assisted with the inspection. LPA conducted a walk-through of the facility inside and out. Facility staff-client ratio at time of inspection 3 staff and 2 clients. LPA interview 3 staff and 3 clients. LPA observed 4 bedrooms and 4 bathrooms. LPA inspected and reviewed the following: Physical Plant License, Mental Health Certification, and Personal Rights posted COVID-19 information is posted, along with a check-in area by the front door that has a sign-in log, thermometer, sanitizer, and disinfectant wipes. Disinfectants/cleaning solutions inaccessible Nonperishable Foods one week and fresh perishable foods two days minimum Menu present and posted Carbon monoxide detector and Smoke Detector fully functioning First Aid Kit fully stocked Common Room available and Dining area with enough seating, furniture in good condition Medication centrally stored and locked Staff Office (locked and privacy) Hot Water between 105-120 degree F and 2 fully charger Fire Extinguishers Page 1 of Toilets wash basin, bath and shower fixtures in good repair There are Soap and Paper towels Laundry Facilities are available and fully functioning Bedrooms have required linen and furnishings are in good repair Motor Vehicle properly maintained, lights and working seat belts. The front right tire needs to be changed, The facility had vehicle inspected immediately and will be serviced. Facility free of vermin Disaster Preparedness Disaster and mass casualty plan updated and available Monthly Drills conducted and documented Staffing Records Staff files reviewed Criminal record clearances verified First Aid Certificates are current Certified Administrators certificate valid and current, job title/qualification verified, Hours required training verified. Hours required annual training verified Client Records Clients files reviewed Needs and Services Plans are not signed and will be corrected. Centrally Stored Medication and log reviewed Psychotropic Medication and log reviewed Cash Resources and Personal Property reviewed Page 2 of Core/Therapeutic Services Trauma Informed Practices are implemented as needed (including specialty mental health services and extracurricular activities and social supports).The following items were reviewed for compliance in the regional office prior to the facility inspection: · Annual fees are overdue. Outstanding amount is $4,767.00, payment will be submitted. The facility has been provided with a history of outstanding fees. · Administrator Certificate for: Staci Exceus · Emergency Disaster Plan (per H&S Code 1565) · Accreditation Name and Expiration Date: 8/3/2022 · Mental Health Program Certificate Expires: 5/21/2022 · Personnel Roster, Facility Sketch, LIC 500, LIC 610C and LIC An exit interview was conducted with Staci Exceus and a copy of this report email to sexceus@c4pc.com. Page 3 of 3

met_with: Staci Exceus


summary: Facility Evaluation

raw_content:
Narrative:
On 08/30/22 at 2:00 p.m. Licensing Program Analyst (LPA), Jacqueline Carmona made an unannounced visit to conduct a case management regarding an incident report received by the Department on 08/25/22 regarding staff error in administering medication. LPA met with Maria Felise, Facility Manager who assisted with the inspection. The STRTP is a two story home. It consists of two living spaces, one dinning room, one kitchen, four bedrooms (three client bedrooms, one bedroom used for therapy sessions and group sessions),3.5 bathrooms, a laundry room, and a large room used as the Facility Manager and Therapist office. LPA conducted interviews with the facility manager, one client, one staff member, and gathered the following documentation: staff member training logs, medication logs, and staff roster. An exit interview was conducted with Maria Felise, House Manager and a copy of this report will be emailed to Co-Director, Shavonne Powell. This case management investigation needs further investigation.

met_with: Maria Felise, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 2/28/23 at 1:40 p.m. Licensing Program Analyst (LPA), Jacqueline Carmona made an unannounced visit to conduct a case management at the above facility regarding their annual mental health program review conducted on February 1-2, 2023 by the Department of Health Care Services. In addition, to follow up on Yolo County's rescinding letter of support dated 1/20/23. LPA Carmona met with Shavonne Powell, Agency Director who assisted with the inspection. The STRTP is a two-story home. It consists of two living spaces, one dining room, one kitchen, four bedrooms (three client bedrooms, one bedroom used for therapy sessions and group sessions),3.5 bathrooms, a laundry room, and a large room used as the Facility Manager and Therapist office. Based on the deficiencies cited during the review of the facilities compliance with Mental Health Program Approval (MHPA) the facility is now on a corrective action plan which is due on March 15, 2023. LPA Carmona reviewed the deficiencies with Agency Director, Shavonne Powell on the following sections: 6,8,9,10,11,12,13,14,15,16,17, and 18. LPA Carmona also discussed Yolo County rescinding letter of approval for the mental health contract and medical certification dated 1/20/23. The letter states Yolo County CWS lacks confidence in Center for Positive Changes' ability to provide the appropriate level of care required for dependent youth placed at their Short-Term Residential Treatment Program (STRTP) for the following reasons: • Inability to provide adequate specialty mental health services • Lack of psychiatric services • Multiple denials of admission for Yolo County Child Welfare (CWS) dependents • Frequency of calls to local law enforcement regarding youth that have left the facility Continue to page During the visit the Agency Director stated that the corrective action plan is still under process and will be completed by 3/15/23. The facility is now fully staffed. The Agency Director stated they have decided to move on with the head of service who was pending finger print clearance and they will now on board their former head of service. The reason why they received repeated deficiencies for their mental health program annual review is due to the fact they did not have access to avatar which caused the back log in entering progress notes and assessments. In addition, the provider stated they have reached out via a telephone call and via email to Yolo County to receive guidance as to what is the next step and as of yet have not received a response. An exit interview was conducted with Agency Director and a copy of this report was provided. LPA Carmona will follow up with the facilities plan of correction from DHCS and the outcome with Yolo County.

met_with: Agency Director, Shavonne Powell


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 4/25/23 at approximately 9:12 a.m. Licensing Program Manager (LPM) Rosa Rodriguez and Licensing Program Analyst (LPA) Jacqueline Carmona made an unannounced annual inspection using the Compliance and Regulatory Enforcement (CARE) tools and met with Administrative Assistant, Jessica Moomey and Administrator, Staci Exceus. LPA toured the interior and exterior of the facility during the inspection today. The facility is two stories and the second floor consists of 1 bedroom used for therapy sessions, 3 client bedrooms, which had all the adequate furniture (twin sized beds and storage units), linens and lighting as required. LPA observed 2 bathrooms available to clients which were appropriately equipped with toilet paper, paper towels and running warm water at temperature of 113 degrees. LPA observed that the shower and toilets were in working condition as required. LPA observed the laundry services available for the youth to complete their own laundry. The first floor consists of a kitchen which had an adequate supply of perishable and nonperishable food for the clients in care. LPA observed that the facility appliances, refrigerator, and freezer to be clean and function as required. LPA observed that sharps, disinfectants, and cleaning supplies were appropriately stored and were not accessible to clients in care. LPA observed a menu posted in the facility. LPA observed working carbon monoxide detectors and a fully charged fire extinguisher. LPA observed that the facility has a functioning telephone in the facility. The 2 living rooms and dining room were free of obstruction and had furniture in good repair. The staff office has a locked cabinet for client's files, a locked cabinet for medication, and 1 bathrooms which is appropriately equipped with toilet paper, paper towels and running warm water as required . All the posting requirements were available in a visible area. First aid kit was fully stocked and available. LPA observed that the facility vehicles to be in good operating condition. The back yard and front yard were free of debris. LPA observed the lawns to need mowing and bushes need trimming. There are no bodies of water located on the property. Continue to page Currently the facility has 2 clients in care. LPA reviewed 4 client files and 5 staff files. A review of the staff files indicated the staff have current CPR and First Aid training. They also have DOJ, FBI, and Child Abuse check clearances. LPA interviewed 7 staff , 1 client, and attempted 1 client interview. A review of the Licensing Information System indicates the facility is current with their facility fees. Exit interview was conducted. Two type B deficiencies and Technical Violations (TV) were cited during todays inspection. Personnel Requirements 87065(c) (1)(A) and 87065 (f), refer to LIC9099D. A copy of report was provided to the Administrator.

Deficiencies:
87065(f): Personnel Requirements

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


summary: Facility Evaluation

raw_content:
Narrative:
On 5/16/23 at 11:00 a.m. Licensing Program Analyst (LPA), Jacqueline Carmona made an unannounced visit to the Short Term Residential Therapeutic Program (STRTP) to conduct a case management regarding the facility staff not having knowledge of Mandated Reporting, The Facility Program Statement and Needs and Service Plan. LPA met with LaChandia Johnson, Facility Manager (who assisted with the inspection). The STRTP is a two-story home. It consists of two living spaces, one dining room, one kitchen, four bedrooms (three client bedrooms, one bedroom used for therapy sessions and group sessions),3.5 bathrooms, a laundry room, and a large room used as the Facility Manager and Therapist office. A walk through was conducted during today's inspection, the facility was observed to be in compliance. On 4/25/ LPA Carmona conducted the facilities annual inspection. During the staff interviews, 4 out of 7 staff members were unable to answer questions regarding Mandating Reporting, the facilities Program Statement and Needs and Service Plan. An exit interview was conducted with LaChandia Johnson, Facility Manager and a copy of this report was provided. There were no citations during today's visit. This case management investigation remains open until the training is conducted with the staff members and proof of training is submitted to LPA Carmona by 6/16/23.

met_with: LaChandia Johnson, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On 5/16/23 at 11:00 a.m. Licensing Program Analyst (LPA), Jacqueline Carmona made an unannounced visit to the Short Term Residential Therapeutic Program (STRTP) to conduct a case management on building and grounds. LPA met with LaChandia Johnson, Facility Manager (who assisted with the inspection). The STRTP is a two story home. It consists of two living spaces, one dining room, one kitchen, four bedrooms (three client bedrooms, one bedroom used for therapy sessions and group sessions),3.5 bathrooms, a laundry room, and a large room used as the Facility Manager and Therapist office. A walk through was conducted during today's inspection. The interior of the facility was in compliance. During the walk through of the exterior of the facility LPA Carmona observed one window screen missing in the front dinning room window and a broken bedroom window on the right side of the house. The broken window is in an unoccupied bedroom and is covered with plywood. In addition, LPA Carmona observed the lawn in need of maintenance such as mowing in the back yard. LPA Carmona was provided documentation of a work order for the window screen dated 4/25/23 and a purchase receipt for the new window dated 5/04/23. LPA Carmona was informed the yard is mowed on a biweekly schedule but no supporting documentation was provided during todays inspection. An exit interview was conducted with LaChandia Johnson, Facility Manager and a copy of this report was provided. There were no citations during today's visit because a work order was in place. LPA Carmona will obtain contact information for the landscaping company to ensure they are providing services biweekly. This case management investigation remains open until documentation is submitted to LPA Carmona of the installation of the new window and window screen. A follow up inspection will be conducted once the documentation is received to ensure the facility is incompliance.


summary: Facility Evaluation

raw_content:
Narrative:
On 6/30/23 at 10:35 a.m. Licensing Program Analyst (LPA), Jacqueline Carmona made an unannounced visit to the Short Term Residential Therapeutic Program (STRTP) to close a case management regarding the facility staff not having knowledge of Mandated Reporting, The Facility Program Statement and Needs and Service Plan. LPA met with Staci Exceus, Administrator (who assisted with the inspection). The STRTP is a two-story home. It consists of two living spaces, one dining room, one kitchen, four bedrooms (three client bedrooms, one bedroom used for therapy sessions and group sessions),3.5 bathrooms, a laundry room, and a large room used as the Facility Manager and Therapist office. A walk through was conducted during today's inspection, the facility was observed to be in compliance. On 4/25/ LPA Carmona conducted the facilities annual inspection. During the staff interviews, 4 out of 7 staff members were unable to answer questions regarding Mandating Reporting, the facilities Program Statement and Needs and Service Plan. On 6/16/ LPA Carmona received documentation of agendas and sign in sheets dated 5/25/23,6/01/23, and 6/08/23 for training that occurred on the topics above. An exit interview was conducted and a copy of this report was provided to Staci Exceus, Administrator.This case management investigation is closed.


summary: Facility Evaluation

raw_content:
Narrative:
On 6/30/23 at 10:35 a.m. Licensing Program Analyst (LPA), Jacqueline Carmona made an unannounced visit to the Short Term Residential Therapeutic Program (STRTP) to conduct a case management on building and grounds. LPA met with Staci Exceus, Administrator (who assisted with the inspection). The STRTP is a two story home. It consists of two living spaces, one dining room, one kitchen, four bedrooms (three client bedrooms, one bedroom used for therapy sessions and group sessions),3.5 bathrooms, a laundry room, and a large room used as the Facility Manager and Therapist office. A walk through was conducted during an inspection. The interior of the facility was in compliance. During the walk through of the exterior of the facility LPA Carmona observed one window screen missing in the front dining room window and a broken bedroom window on the right side of the house. The broken window was in an unoccupied bedroom and is covered with plywood. In addition, LPA Carmona observed the lawn in need of maintenance such as mowing in the back yard. On 5/16/ LPA Carmona was provided documentation of a work order for the window screen dated 4/25/23 and a purchase receipt for the new window dated 5/04/23. LPA Carmona was informed the yard is mowed on a biweekly schedule. On 5/19/ LPA Carmona was sent lawn service receipt's for the months of January 2023 through April 2023. On 6/30/ LPA Carmona conducted a follow up inspection at the facility and observed that the window has been replaced, the screen for the other window was also replaced, and the lawn was observed to be maintained. An exit interview was conducted with Staci Exceus, Administrator and a copy of this report was provided. This case management investigation is closed.


summary: Facility Evaluation

raw_content:
Narrative:
On 6/30/ Licensing Program Analyst (LPA) Jacqueline Carmona conducted an on-site inspection to the above facility. LPA met with the Staci Exceus, Administrator. The purpose of this inspection was to confirm that the Short Term Residential Therapeutic Program (STRTP) had been vacated of clients. LPA Carmona was given a tour of the interior and exterior of the home. There were no indications of ongoing placement's observed. During todays on site inspection LPA Carmona was formally notified of this closure via an in person conversation. LPA Carmona will be provided a written closure request letter by end of business day today. The reason for the closure is due to the facility loosing the letter of support from Yolo County. The posted license was surrendered. The Regional Office is in agreement to waive 50% of the annual fees totaling $227. The facility will be closed effective 6/30/23. No citations were issued as a result of this inspection. Exit interview conducted; a copy of this report was provided to Staci Exceus, Administrator .


summary: Facility Evaluation

raw_content:
Narrative:
On 8/20/2021 at 2:00pm Licensing Program Analyst (LPA) N. Sanders contacted the above facility to address serious of incident reports involving one minor missing medications. LPA spoke with Trayvon Kennedy, House Manager LPA conducted interviews and collected documents. It was observed that Foster Youth missed his JV220 on four different occasions due to the fact that it was expired. Reviewed documentation and conducted interviews show it was not ensured that that client had his prescribed medication. Client missed JV220 four times. Case Management was finalized on 8/27/2021. On this day LPA arrived at the above facility met with Shavonne Powell, Co-Director. The Facility is cited for California Code of Regulations (CCR), Title 22, division 6, Chapter 1, for missed medications, 80075(b)(5)(B) Health Related Services. Medications shall be given according to physician's directions. A copy of this report and appeal rights were emailed Shavonne Powell , Co-Director.

met_with: Staci Excuses, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On November 4, 2021 at 10:15AM Licensing Program Analyst (LPA), Yuvi Diaz made an unannounced visit to conduct a case management regarding an incident report received by The Department on 10/06/21 regarding Lack of Supervision. LPA met with Trayvon Kennedy(who assisted with the inspection). STRTP is a two story home it consists of two living spaces, one dinning room, one kitchen, four bedrooms, 2.5 bathrooms, laundry room, and large office room for the therapist and rehabilitation specialist. The incident which occurred on 10/06/21 involving a staff memebers and client in a verbal altercation, resulting staff leaving client unsupervised at the facility for about 45 minutes until shift partner returned to facility. Based on interviews conducted with Administrator, staff, clients, and former staff, it was confirmed that the incident took placed. The facility wrote an incident report and staff members were terminated on October 11, 2021. An exit interview was conducted with Trayvon Kennedy and a copy of this report was given to the Administrator (or report was left at the facility). This case management investigation is closed, and the facility has been cited for Lack of Supervision (See LIC 809D).


summary: Facility Evaluation

raw_content:
Narrative:
On 09/09/22 at 2:38 p.m. Licensing Program Analyst (LPA), Jacqueline Carmona made an unannounced visit to conduct a case management of an incident report received by the Department on 08/25/22 regarding staff error in administering medication to the incorrect client. LPA Carmona met with Staci Exeus, Administrator who assisted with the inspection. The STRTP is a two story home. It consists of two living spaces, one dinning room, one kitchen, four bedrooms (three client bedrooms, one bedroom used for therapy sessions and group sessions),3.5 bathrooms, a laundry room, and a large room used as the Facility Manager and Therapist office. Based on interviews conducted with Facility Manager, Staff, and Clients. It was confirmed that the incident took place. On 08/24/ S2 delivered medication to the incorrect school and administered it to C2 instead of C1. In addition, the medication error caused C1 to miss their intended dose that morning. An exit interview was conducted. Appeals Rights were discussed and a copy of this report and Appeal Rights were emailed to Staci Exeus, Administrator at sexceus@c4pc.com. This case management investigation is closed, The facility has been cited for Health Related Services (See LIC809D).

met_with: Staci Exeus, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 1/19/23 at 10:40 a.m. Licensing Program Analyst (LPA) Jacqueline Carmona made an unannounced visit to the Short Term Residential Therapeutic Program (STRTP) above to conduct a case management regarding full incident reports not being submitted to Community Care Licensing within 7 days. LPA Carmona met with Shavonne Powell, Agency Director (who assisted with the inspection). The STRTP is a two-story home and consists of two living spaces, one dining room, one kitchen, four bedrooms, 2.5 bathrooms, laundry room, and large office room for the therapist and rehabilitation specialist. On 12/27/22 the Department received two 24-hour incident reports for two clients. The facility has not submitted the full incident reports for the two clients dated 12/23/22 and 12/27/22. LPA Carmona reminded the Agency Director that incident reports must not only be reported within 24 hours, but a full report must also be submitted within 7 days to the CCLSacChicoIncidents@dss.ca.gov. On 3/18/22 the facility received a technical violation regarding the same matter. Shavonne Powell informed LPA Carmona moving forward they will ensure the full reports are submitted within 7 days. An exit interview was conducted with Shavonne Powell, Agency Director. A copy of this report and Appeal Rights was provided. This case management investigation is closed, and the facility has been cited for Reporting Requirements (See LIC 809D).


summary: Facility Evaluation

raw_content:
Narrative:
On 5/16/23 at 11:00 a.m. Licensing Program Analyst (LPA), Jacqueline Carmona made an unannounced visit to the Short Term Residential Therapeutic Program (STRTP) to conduct a case management regarding the facility not having a Head of Service. LPA met with LaChandia Johnson, Facility Manager (who assisted with the inspection). The STRTP is a two-story home. It consists of two living spaces, one dining room, one kitchen, four bedrooms (three client bedrooms, one bedroom used for therapy sessions and group sessions),3.5 bathrooms, a laundry room, and a large room used as the Facility Manager and Therapist office. A walk through was conducted during today's inspection, the facility was observed to be in compliance. The Department was notified by the provider via an email on 1/09/23 that they no longer had a Head of Service effective 12/31/22. They stated they were in the process of on boarding and training a new potential Head of Service. On 4/27/23 the provider notified the Department via email stating they will utilize a Head of Service from San Diego County who would provide services remotely until they identify another candidate as they still are interviewing and waiting background clearances. As of 5/16/23 the provider confirmed that the facility still has no Head of Service in the facility to provide the Mental Health Services to the clients in care and the provider is continuing to interview for a potential Head of Service during this process and waiting on background clearances. An exit interview was conducted with LaChandia Johnson, Facility Manager and a copy of this report and the Appeal Rights were provided during today's visit. This case management investigation is closed, and the facility has been cited under Plan of Operations, Interim Licensing Standard (ILS) Section 87022(f) (See LIC 809D).


facility_name: CENTER FOR POSITIVE CHANGES 2

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews provided consistent statements of bubble pack containing psychotropic medication missing pills. Record review was unable to determine what had happened to the medication. Both confidential interviews and record review revealed an internal investigation was completed regarding the missing medication and was unsuccessful in determining what happened to the medication. Based on confidential interviews and record review, there is sufficient evidence to support that staff mismanaged youth's medication. The complaint is valid because the preponderance of evidence standard has been met. The facility is being cited for violation of Interim Licensing Standards (ILS) standard 87070(b)(14)(F-H). CHILDREN'S RECORDS 87075(B)(14) a separate log for each psychotropic mediation prescribed to a child documenting tall of the following: (F) The date and time of each dose taken by the child, (G) Documentation of each refusal, (H) Staff initials for each time a psychotropic medication is taken by a child, as an indication that they supervised the child self-administering their psychotropic medication. A copy of this report, including appeal rights, was discussed with and provided to Maria Alonso, Administrator of Center for Positive Change STRTP.

Investigation Findings:
13On October 22, 2025, at 10:15 a.m., Licensing Program Analyst (LPA) Jacob Ortega met with Administrator Maria Alonso Center for Positive Change Short-Term Residential Therapeutic Program (STRTP), to deliver the finding for the above-stated allegation. A Health and Safety inspection was conducted on April 21, 2025, and no immediate health or safety hazards were observed at that time. The investigation was conducted by LPA Jacob Salem and LPA Ortega and included interviews with four staff (S1,S2,S5,S6), four clients (C1-C4), county social worker (CSW3), and probation officer (PO). Additionally, county, facility, and client records were reviewed. On April 14, 2025, Community Care Licensing (CCL) received a complaint alleging that staff mismanaged a youth's medication. Specifically, it was reported a review of facilities psychotropic medication logs and corresponding psychotropic bubble packs for the month of April 2025 revealed medication was missing and there waws no documentation to account for missing medication. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Nicole Strickland LICENSING EVALUATOR NAME: Jacob Ortega 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: CENTER FOR POSITIVE CHANGES 2FACILITY NUMBER: VISIT DATE: 10/22/2025

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

met_with: Administrator Maria Alonso

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
On February 25, 2025, at 10: AM, Licensing Program Analyst (LPA) Jacob Salem met with Amber Jansen, Chief Operations Officer (COO) of Center for Positive Changes for the purpose of conducting a pre-licensing inspection for a Short Term Residential Treatment Program. Center for Positive Changes is applying for a license for six ambulatory children and Non-Minor Dependents. The home is a two story residence located on a residential street. LPA and COO Jansen toured the home inside and out. The home is currently empty and partially unfurnished due to the licensee's current facility still utilizing the furniture and other supplies. LPA observed the applicant's current facility to be in compliance and contain all the necessary provisions, such as bedding and storage closet for files and medications, and COO Jansen stated that all furniture and equipment currently in use will be brought to the new home upon relocating with the clients in care. The current home contains a kitchen, two living rooms, garage, backyard and therapy offices, and staff office where client files and medications will be stored. The license, LIC 610C, and Personal rights will be posted in the entrance upon the clients relocating to the home. The bedrooms will be set up as follows: - Bedroom 1: sleeping two clients downstairs - Bedroom 2: sleeping one client downstairs - Bedroom 3: sleeping one client downstairs - Bedroom 4: sleeping two clients upstairs The client bedrooms will have ample lighting and adequate storage space for clothing and personal belongings. The applicant has working and recently inspected fire extinguishers and a first-aid kit. The kitchen contains working and clean appliances for food preparation, storage, and cleaning. Continued... ...CONTINUED There were no safety or health hazards observed during the walk though of the home and property. There is a central heating/air conditioning unit in the home located downstairs and the home is kept at a comfortable temperature. Client bathrooms are clean and appliances are in working order and sinks were tests to run at 116.6 and 119.7 degrees F. Windows and screens were inspected and are in good repair. The facility has demonstrated compliance with Title 22, Division 6 of the California Code of Regulations and Interim Licensing Standards. An exit interview was conducted and a copy of this report was provided to Amber Jansen, Chief Operations Officer of Center for Positive Changes.

visit_type: Prelicensing

met_with: Amber Jansen, Chief Operations Officer


summary: Facility Evaluation

raw_content:
Narrative:
On April 10, 2025 at 10: AM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced visit to the above facility for the purpose of conducting an post-licensing inspection and met with Kendrick Johnson, Facility Manager. LPA reviewed the facility's emergency disaster plan and provisions. LPA inspected the facility's physical plant, including personal rights postings, health-related services, buildings and grounds, food services, indoor and outdoor activity space, and furniture, fixtures, equipment and supplies. The home is clean, in good repair, and free from observable risks to clients' health, safety, and personal rights. The home is a two story building with four client bedrooms and two client bathrooms which are set up as follows: bedroom #1 sleeps two clients downstairs, bedroom #2 sleeps one client downstairs, bedroom #3 sleeps one client downstairs, bedroom #4 sleeps two clients upstairs. There is a kitchen and living room, seperate office in backyard for therapy and visitation, staff office and storage closets, and backyard/patio. LPA conducted one staff and one client interview. Due to time constraints, the inspection is being extended to conduct a file reviews and complete staff and client interviews. An exit interview was conducted and a signed copy of this report was provided to Kendrick Johnson, Facility Manager.

met_with: Kendrick Johnson, Facility Manager