summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Les Inouye met with Director Alicia Carroll by phone to discuss current status of application. Carroll advised LPA that the latest review has be uploaded to the Onedrive and she would highlight any and all changes since the last submission. Carroll also advised LPA that Rosemary Murilio has completed her Administrator classes and submitted and is waiting for approval. LPA advised that a review will be completed by 5/27/25 and a phone call status would be made to advise Carroll of corrections or completion. LPA also advised Carroll that a expedited request for Rosemary's Administrators Certificate would be made. On 5/27 a status and plan would be made to complete the application.

met_with: Alicia Carroll


state: CA

facility_name: TURNING POINT OF CENTRAL CALIFORNIA INC.-ATLANTIS

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Les Inouye met with Director Alicia Carroll by phone to discuss current status of application. LPA let Carroll know that there are few issues with the Program Statement and can be completed quickly. Carroll advised LPA that she has not completed the highlighting of additional information for this last review. LPA advised that the review is almost complete and it is not necessary to highlight new information at this time. Carroll advised LPA that it will take her a few hours to return any new updates. LPA asked what is the projected licensing date. Carroll advised that it is 6/2/25 if Mountain Valley Regional Center (MVRC) does not have any objections with their program. Carroll with advise LPA is there are any setbacks on projection dates. Carroll advised LPA that Rosemary Murilio has received her Administrator Certificate hours after our last conversation. LPA inquired if Raymond Banks is a current Board Member as printed in Guardian. Carroll confirmed he is. LPA advised Carroll that a review will be sent to her with in the next day and a return date will be dependent on any issues MVRC has with their program.

report_type: Facility Evaluation

visit_type: Case Management


facility_name: VERNELLA TRANSITIONAL HOME-3

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Although the allegation may have happened are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegation of Personal Rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. An exit interview was conducted, and a copy of this report was left at the Program Administrator.

Investigation Findings:
13On December 6,2022, at 10: AM Licensing Program Analyst (LPA), Rosslyn Gray made an unannounced visit to VERNELLA TRANSITIONAL HOME-3 to conclude the investigation on the above allegation. LPA met with the Program Administrator to conclude the investigation and to deliver the findings. During the investigation LPA-Gray interviewed and accounted for all available relevant parties; and gathered pertinent information regarding the allegation. Based on the interviews and statements obtained during the investigation process, the allegation cannot be corroborated because supporting evidence includes the following: The Licensee denied the allegation and the alleged victim denied the allegation of personal rights. There is no evidence or witnesses to support that the facility "Staff not treating minor with dignity. Confidential interviews were congruent and confirmed that the staff followed directives accordingly to provide the proper care, and treated the alleged victim and other youth in placement with dignity and respect. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Rosslyn Y. Gray LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: VERNELLA TRANSITIONAL HOME-3FACILITY NUMBER: VISIT DATE: 12/06/2022

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

report_type: Complaint Investigation

met_with: Program Administrator

complaint_status: unsubstantiated


raw_content:
Narrative:
Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. There are no deficiencies cited at this time. An exit interview was conducted, and a copy of this report was left with the Melvora Moore Fulton - Program Administrator.

Investigation Findings:
13On October 15,2024, at 10: AM, Licensing Program Analyst (LPA), Rosslyn Gray made an unannounced visit to conclude the investigation. Prior to entering the facility LPA Gray conducted a health and safety risk assessment. During the investigation, LPA Gray interviewed all available parties, and reviewed video and documentary evidence. Confidential statements did not corroborate allegations. Licensee denied the allegations. Child 1(C1) was unable to provide a statement pertaining to the allegations. Review of video evidence did not provide a clear view or observation of Staff 2 (S2) handling C1 in a rough manner. S2 was also not observed to speak to C1 inappropriately. Statements indicated that routine body checks of clients in care are conducted and documented. There were no witnesses or documentary evidence to corroborate allegations. Due to a lack of evidence obtained during the investigation,LPA determined that the allegations are Unsubstantiated.. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Rosslyn Y. Gray LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: VERNELLA TRANSITIONAL HOME-3FACILITY NUMBER: VISIT DATE: 10/15/2024

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


summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13Licensing Program Analyst Connie Jones-Steward investigated the above allegation. LPA interviewed staff members, C1 and C1's mother. The conclusions of the investigation are that the client did receive his birthday dinner on the day "after" his birthday. However the reasons for the delayed dinner are in dispute. Staff alleges that the dinner was delayed because C1 returned home late on the night of his birthday. C1's Bio Mom refutes this as the reason. C1 could not remember exactly where he was on the night of his birthday. Due to conflicting information, this allegation is resolved as "unsubstantiated". Unsubstantiated means that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward 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: 2 of 2

met_with: Melvora Moore-Fulton, CEO/Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward arrived at the facility at 2: PM to conduct the post-licensing inspection. However LPA found to the home to be under minor construction due to findings by the City of Compton that un-permitted additions to the home had been completed prior to Dr. Moore-Fulton purchasing the house. LPA did not observe any dangers to the clients in care. Dr. Moore-Fulton estimates that the construction will be completed by the week of 01/17/22. LPA advised Dr. Moore-Fulton to submit a letter detailing the necessary construction and also the measures that are being taken to keep the clients safe. LPA will return to the home to complete the post-licensing inspection after the construction work is complete.

met_with: Melvora Moore-Fulton


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward met with lead staff Orlando Omoruyi to follow up on the incident of 05/01/22. Dr. Moore-Fulton joined about 15 minutes into the interview. In this incident Client #1 was reported to have assaulted a staff member with a metal pole that he found in the backyard. Mr. Ompruyi states he was not on duty during the incident and does not know the details. However he states that the backyard is kept free of hazards. LPA Jones-Steward observed the backyard as well as the yard areas along side the house. Client reported that he hit staff with a pole that was used to hold up a tree. LPA observed a white pole that was stuck loosely into the ground and used to support a small tree. LPA advised Mr. Omoruyi that the pole needs to be secured into the ground or removed. Mr. Omoruyi removed the pole and locked it in the tool shed.

met_with: Orlando Omoruyi/Melvora Fulton-Moore


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward met with Administrator Asst. Miyoshi Morrow and Administrator Melvora Moore-Fulton to conduct the annual required inspection. The following was observed. This is a single story, single family home located in a residential area of the City of Compton. There are currently 4 clients assigned to the facility. Client #3 is on AWOL status and only shows up to receive her allowance. Per Ms. Morrow, a 30 day discharge was submitted to the regional center on July 6, 2022 for client #3. However the regional center has instructed the facility to keep the bed open until they can figure out what to do with her. LPA observed that the yard area was free of visible hazards. There are no bodies of water on the premises. The home has the required smoke and carbon monoxide detectors. All hazardous items including knives, household chemicals and medications are safely stored under lock and key.There are no security bars on windows, hot water temperature is within acceptable range, there are no fireplaces. There was a disaster drill conducted on 06/22/ Food supply meets Title 22 requirements for perishable and non-perishable foods. Refrigerator and kitchen stove are in good working order. There is a current menu posted. The following are also posted: Floor plan, employee schedule, notice of employee rights and client complaint procedure. Restraint log and medication logs were reviewed. LPA interviewed the one client who was present at time of inspection. LPA will interview staff at a later date. There were no deficiencies cited during this inspection

visit_type: Annual

met_with: Dr. Melvora Moore-Fulton.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward conducted the post-licensing inspection on this date. LPA arrived to the facility at 9:30 and was granted entrance by administrative assistant Miyoshi Morrow. Dr. Moore-Fulton assisted with the inspection. The following was observed during the tour of the facility. This is a four bedroom, 2 bathroom home located in a residential section to the City of Compton, CA. There are currently four clients in placement. There are no security bars, firearms or fireplaces on the premises. There is a security system and sprinkler system in place, There is a surveillance system with cameras that do not face into bedrooms or bathrooms. The surveillance system is video only. The backyard area was free of visible hazards. There are no bodies of water. There is a locked storage shed for tools and equipment. All smoke and carbon monoxide detectors are working and properly placed. There is a fully charged fire extinguisher in the facility. Bathroom and kitchen equipment is in good working order. There is sufficient food to meet the Title 22 requirements. All sharp knives, household cleaners and medications are secured in locked cabinets All bedrooms have beds and linens in good condition. There is sufficient storage space to meet Title 22 requirements. Client and staff files will be reviewed during the upcoming annual inspection. There were no deficiencies cited on this date.

met_with: Miyosi Morrow, Melvora Moore-Fulton


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward conducted the annual required inspection on this date. Dr. Moore-Fulton and Esperanza Sanchez assisted with the inspection. The following was observed during the tour of the facility. This is a four bedroom, 2 bathroom home located in a residential section to the City of Compton, CA. There are currently four clients in placement. There are no security bars, firearms or fireplaces on the premises. Windows are operational. There is a security system and sprinkler system in place, There is a surveillance system with cameras that do not face into bedrooms or bathrooms. The surveillance system is video only. There are working smoke detectors and carbon monoxide detectors in the facility. There is a fully charged fire extinguisher in the facility. The backyard area was free of visible hazards. There are no bodies of water. There is a locked storage shed for tools and equipment. There is a fully stocked first aid kit on the premises. Bathroom and kitchen equipment is in good working order. There is sufficient food to meet the Title 22 requirements. All sharp knives, household cleaners and medications are secured in locked cabinets All bedrooms have beds and linens in good condition. There is sufficient storage space to meet Title 22 requirements. Floor plan, menu, license and employee schedule are posted as required. The last disaster drill was documented as of 03/11/23. LPA interviewed one client. Of the other 3, one was not feeling well, one is non-verbal and one is hospitalized. LPA reviewed client records. Staff record reviews and interviews will be conducted at a later date. There were no deficiencies cited as a result of this inspection

met_with: Melvora Moore-Fulton, CEO


facility_name: VILLA SANTA ELIZABETH

summary: Facility Evaluation

raw_content:
Narrative:
On September 17, 2024, at 10: AM, Licensing Program Analyst (LPA) Jacob Salem and applicant Richard Enriquez (RE) met at the Community Care Licensing San Diego office for a Component II orientation. LPA and RE went over application revisions and discussed the application process prior to licensure. RE stated that the facility should be ready for fire inspection in two months at the earliest, and LPA advised RE to remain in contact with the fire inspector. A pre-licensing inspection will be scheduled once the applicant's revisions are approved by the Department and fire clearance and criminal background clearance are received. A signed copy of this report was provided to applicant Enriquez.

met_with: Richard Enriquez, Applicant


summary: Facility Evaluation

raw_content:
Narrative:
On July 8, 2025, at 10: AM, Licensing Program Analyst (LPA) Jacob Salem met with Administrator/Applicant Richard Enriquez and Lead Direct Support Professional Salvador Anton for the purpose of conducting a pre-licensing inspection for an Enhanced Behavioral Support Home. Applicant Enriquez is applying for a license for four clients age 12-17, two non-ambulatory. The home is a one story residence located on a residential street. LPA, Applicant Enriquez, and lead DSP toured the home inside and out. LPA inspected the facility's physical plant, including personal rights postings, health related services, buildings and grounds, food services, telephones, 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 current home contains a four client bedrooms, two client bathrooms, kitchen, two open living room areas, staff office, garage, backyard with storage shed, and staff closet and locked file cabinet where client files and medications will be stored. The license will be posted in the front hallway upon licensure. The client bedrooms will be set up as follows: bedroom 1 sleeps one ambulatory client, bedroom 2 sleeps one ambulatory client, bedroom 3 sleeps one non-ambulatory client, and bedroom 4 sleeps one non-ambulatory client. The home has a cental smoke and carbon monoxide detection system, which is connected to the facility's approved delayed egress system, in additional to other protective measures for non-ambulatory clients, such as automatically closing fire door. The home also contains ramps for all entrances and grab bars in the client bathroom next to the bedrooms designated for non-ambulatory clients. The facility has demonstrated compliance with Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided to Administrator/Applicant Richard Enriquez.

visit_type: Prelicensing

met_with: Richard Enriquez, Administrator


facility_name: WALK OF LIFE-JUSTAMERE

raw_content:
Narrative:
the allegation is determined to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, and a copy of the report and appeal process was emailed to the administrator at kayla@walkoflifejustamere.com

Investigation Findings:
UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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

met_with: Administrator


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
The preponderance of the evidence standard has been met; therefore, the above allegation is determined to be SUBSTANTIATED. California Code of Regulations, (CCR 80075 (a)), is being cited on the attached LIC9099D. An exit interview was conducted, a copy of this report reviewed and provided to the group home senior lead along with appeal rights.

Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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

met_with: Group Home Senior Lead

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
Based on LPA's observations and interviews that were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulation, Title22, 84072 (d)(11) is being cited on the attached LIC9099D. Exit interview conducted, a copy of this report and the Appeal Rights will be provided to the Agency.

Investigation Findings:
13On 09/29/2022 at 330pm, Licensing Program Analysts (LPA), Tana Kinder conducted an unannounced inspection to deliver complaint findings with the administrator. Prior to the meeting, LPA Kinder 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 conducted an inspection of the facility inside and out, on 7/26/22, and no citations were issued. LPA conducted 6 confidential interviews between 7/25/2022-8/9/2022. LPA obtained and reviewed the following documents: IPP and behavior plan for 1 client, staff training related to client's behavior. Although the youth in the complaint is unable to corroborate the allegation, five interviews do corroborate that a minor was hit by staff while in care at the facility. This includes confirmation from the staff member that engaged in the incident against the youth. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Tana Kinder 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: WALK OF LIFE - JUSTAMEREFACILITY NUMBER: VISIT DATE: 09/29/2022

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


summary: Facility Evaluation

raw_content:
Narrative:
An annual required inspection was conducted by Licensing Program Analyst (LPA) Tana Kinder on 3/02/2022 with Senior Lead DSP/DSP. Criminal record clearances were reviewed, and the facility is in compliance. Community Care Licensing file, incident reports, facility roster, facility profile and complaint history were reviewed prior to visit at the agency. The licensing fees are current. The EBSH Facility has a capacity of 4 and currently 1 resident. There are 21 staff members associated to the license and 3 currently working at the EBSH Facility. LPA reviewed 5 staff files, all which were reviewed were complete and up to date. Staff files reviewed have required training hours, education, and fingerprint clearances. 1 child file was reviewed. The child's needs and services plan/Individual Program Plan, Behavioral Plan (IBST) and quarterly reviews were complete and up to date. Immunization records were current. Medical consent forms were signed by authorized representative and current. Additionally, the child's file had a record of personal property. Personal rights, menu, license and emergency exit plan were posted. The facility was inspected jointly with Teja Ordonez-Phillips, Senior Lead DSP/RBT of the EBSH Facility. LPA attempted to interview 1 client, but due to their diagnosis of intellectual disability and Autism, the client was not able to communicate verbally. There are 4 bedrooms and 2 bathrooms. Each client's bedroom had a firm mattress, with a bed cover, sheets, blanket and pillows. Additionally there is a sensory room for the clients to play in. The common area has couches and chairs to sit in, a TV and an in-door basketball hoop game for the clients. The facility is in good repair. There are cabinets in the laundry room with additional linen if needed for the bedrooms and the bathrooms. Additionally, each bedroom also has extra linen available. Client and staff files are in locked cabinets, in a locked office. The passageways from the front to the back of the facility are unobstructed. LPA observed 2 locked sheds in the backyard with facility supplies and client belongings and 1 unlocked shed with toys/equipment for the clients. LPA observed enough perishable/non-perishable food for 1 client for 4 days/2 weeks. Smoke detectors are in working order. There is a carbon monoxide monitor and 2 fully charged fire extinguishers. Continued... Disinfectants and cleaning solutions were in a locked cabinet in the laundry room. Sharps were kept locked in the office. The kitchen was stocked with plates, utensils and drinking cups sufficient for 4 clients. The water temperature from the bathroom faucet was 105.4 degrees. Medication disbursement is logged using the program, Quick MAR and is cross reconciled with the bubble packs and bottles medications are stored in. The client's hygiene kit was stocked and stored in a locked cabinet in the bathroom. A fully stocked first aid kit is kept in the staff office. Exit interview conducted, and discussed with Teja Ordonez-Phillips,Lead DSP. No citations were issued and a copy of the annual inspection report was provided to the Administrator.

met_with: Senior Lead DSP/DSP


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst, (LPA)Tana Kinder conducted an unannounced inspection on 1/23/2023 at 115pm related to an incident that occurred on 1/22/2023. The incident was reviewed with the Facility Administrator. LPA reviewed documentation and the plan that was developed to address the issue. No citations were issued. An exit interview was conducted and a copy of the report was provided.

met_with: Facility Administrator


facility_name: WONDERLAND OF CHOICES PREMIER SERVICES

raw_content:
Narrative:
During investigation, confidential interviews stated that C1 has a history of exhibiting inappropriate behaviors and states falsehoods. In addition, C1 uses inappropriate sexual language towards staff. A confidential interview indicated that staff discourage C1 from displaying inappropriate behaviors. Furthermore, confidential interviews corroborated that C1 has inappropriate behaviors and uses inappropriate languages for jokes. Based on confidential interviews and a review of pertinent documents, the allegation that staff encouraged C1 to use inappropriate behavior may have occurred, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated. An exit interview was conducted and a copy of this report along with the appeal right were provided to Administrator Evelyn Preston.

Investigation Findings:
13On 05/14/2025 at 1:43PM, Licensing Program Analysts (LPAs) Claudia Aguilera and MaryJane Perez conducted an unannounced visit at Wonderland of Choices Premier Services and met with Administrator Evelyn Preston to deliver the finding for the above stated allegation. On 03/07/2025, Community Care Licensing received a complaint allegation that staff encouraged client to use inappropriate behavior. On 03/17/2025, LPA M. Perez conducted a health and safety inspection of the facility, and no hazards were observed. Lpa M. Perez also obtained pertinent documents. In addition, LPA C. Aguilera interviewed staff 1, 2, 3, 4, 5 and 6 (S1, S2, S3, S4, S5, S6), clients 1,2, and 3 (C1, C2, and C3) and received copies of Individual Program Plan (IPP) and Individual Behavior Support Plan (IBSP). Regarding the allegation that staff encouraged client to use inappropriate behavior, it was specified that C1 pulled their pants down at school and was getting ready to pull their undergarments. C1 said the staff at the group home showed C1 how to do it and advise C1 to do it at school because it would be funny. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Claudia Aguilera LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: WONDERLAND OF CHOICES PREMIER SERVICESFACILITY NUMBER: VISIT DATE: 05/14/2025

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

met_with: Administrator Evelyn Preston


summary: Facility Evaluation

raw_content:
Narrative:
On August 18, 2022 at 10: AM Licensing Program Analyst (LPA) Anne Visaya and Licensing Program Manager (LPM) Abdoulaye Traore arrived at Wonderland of Choices Premier Services Enhanced Behavioral Support Home to conduct a required annual inspection of the facility. LPA and LPM was toured inside and out with House Manager Jodi Lindsay. There were four clients and seven staff including the house manager were present at the facility during the inspection. The home was approved for two non-ambulatory clients and two ambulatory clients age 6-18. The home is a one-story residence and consists of: Bedroom #1 furnished with full bed size, a closet and storage space It sleeps a 16- year old male client Bedroom #2, furnished with a full size bed, a closet and plenty of storage space. It sleeps a 16-year-old male client Bedroom #3 furnished with twin size bed, a closet and storage space it sleeps a 10 year old male client Bedroom #4 furnished with full size bed, a closet and storage space it sleeps a 14 year old male client A dining room with a large table, a furnished living room no fireplace, a kitchen, a pantry, a 2 walk-in handicap access full bathrooms, and the game room/activity area in the garage. All bedrooms were arranged so that no more than two children share a room, and there was one child per bed. No room was commonly used for other purposes other than a bedroom, and no bedroom serves as a passageway to another room. There were adequate drawer and closet space for children's belongings. The smoke and carbon monoxide detectors were checked and were working properly. The laundry room was located in the garage. The bathrooms were clean and in good repair. The hot water was measured to be F degrees. All hazardous items have been properly made inaccessible to areas where clients will have access. The kitchen had adequate cooking supplies and utensils. The medications were stored and locked in a cabinet in the kitchen. Cleansers/chemicals were locked and stored in the kitchen underneath the kitchen sink and additional cleaning supplies were located in the garage. Sharp knives were inaccessible and stored in a locked cabinet in the kitchen. The First Aid Kit was located inside the cabinet in the kitchen and contained all required items. The living room area had a closet with age appropriate games and activities. The garage had activity equipment for clients and laundry area. All windows and screens were in good repair. There were no guns or weapons in the facility as stated by House Manager Jodi Lindsay. There were cameras in the common areas total 3 located in the office, living room and kitchen and outside the facility. The following required posted items were observed accessible to clients: Grievance procedures, personal rights, ombudsman poster, visitation policies, and current menu. Clients medications were observed to be inaccessible and stored in the kitchen cabinet. The medication logs were kept updated and the dispensing records had no discrepancies. LPA and LPM observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There was a variety of snacks available for clients as well. Two clients were interviewed and indicated that they feel safe in the home and accorded their personal rights. Additionally four Staff were interviewed and no issue were found. The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. In the back yard, there was a locked swimming pool inaccessible to clients. The pool was surrounded by a wrought iron fence measured over 6 feet tall with a gate that self-latches and opens outward. The facility had an operable delayed egress and sprinkler systems. Clients files were reviewed and following documents were present: Independent Behavior Support Plan, Individual Program Plan, health records, LIC 621 and medical consent. Staff records including current crisis prevention intervention (CPI), First Aid and CPR were reviewed during the inspection. The facility emergency plan was also reviewed and all staff had the Department of Justice and Child Abuse Clearance Index clearance Based on today's inspection and observations, there are no deficiencies being cited at this time in accordance with Title 22, Division 6, Chapters 1, 5 and 6. A copy of this report was reviewed and given to facility representative, who the administrator Evelyn Preston authorized Jodi Lindsay House Manager. Exit interview conducted and a copy of this report was discussed and provided to Facility Manager this date.

met_with: Jodi Lindsay


summary: Facility Evaluation

raw_content:
Narrative:
On December 8, 2023 at 12: PM Licensing Program Analyst (LPA) Babatunde Aborchie arrived at Wonderland of Choices Premier Services Enhanced Behavioral Support Home to conduct a required annual inspection of the facility. The facility was toured inside and out with House Manager Jodi Lindsay. There were two clients and seven staff in the house. The home was approved for two non-ambulatory clients and two ambulatory clients age 6-18. The home is a one-story residence and consists of: · Bedroom #1 furnished with full-sized bed, a closet and storage space It sleeps a 17-year-old male client · Bedroom #2, furnished with a full-size bed, a closet and plenty of storage space. It sleeps a 17-year-old male client. · Bedroom #3 furnished with twin size hospital bed, a closet and storage space; it sleeps a 11-year-old male client · Bedroom #4 furnished with twin size bed, a closet and storage space; it sleeps a 15-year-old male client · A dining room with two round tables, a furnished living room with no fireplace, a kitchen, a pantry, two walk-in handicapped access full bathrooms, and the game room/activity area in the garage. All bedrooms were arranged so that no more than two children share a room, and there was one child per bed. No room was commonly used for other purposes other than a bedroom, and no bedroom serves as a passageway to another room. There were adequate drawers and closet space for children's belongings. The smoke and carbon monoxide detectors were checked and were working properly. The laundry room was in the garage. The bathrooms were clean and in good repair. The hot water was measured to be F degrees. All hazardous items have been properly made inaccessible to areas where clients will have access. The kitchen had adequate cooking supplies and utensils. The medications were stored and locked in a cabinet in the kitchen. Cleansers/chemicals were locked and stored in the garage. Sharp knives were inaccessible and stored in a locked cabinet in the kitchen. The First Aid Kit was located inside the cabinet in the kitchen and contained all required items. The living room area had a closet with age-appropriate games and activities. The garage had activity equipment for clients and a laundry area. All windows and screens were in good repair. There were no guns or weapons in the facility as stated by House Manager Jodi Lindsay. There were cameras in the common areas total 3 located in the office, living room, kitchen and outside the facility. The following required posted items were observed accessible to clients: Grievance procedures, personal rights, ombudsman poster, visitation policies, and current menu. Clients medications were observed to be inaccessible and stored in the kitchen cabinet. The medication logs were kept updated and the dispensing records had no discrepancies. LPA observed a minimum 7-day non-perishable and a 2-day perishable supply of food. There was a variety of snacks available for clients as well. Two clients were in the house, non-verbal and were observed to be safe in the home. Additionally, three Staff were interviewed and no issues were found. The facility outside the grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. At the back yard, there was a locked swimming pool inaccessible to clients. The pool was surrounded by a wrought iron fence measured over 6 feet tall with a gate that self-latches and opens outward. The facility had an operable delayed egress and sprinkler systems. Clients files were reviewed and the following documents were present: Independent Behavior Support Plan, Individual Program Plan, health records, LIC 621 and medical consent. Staff records including current crisis prevention intervention (CPI), First Aid and CPR were reviewed during the inspection. The facility emergency plan was also reviewed, and all staff had the Department of Justice and Child Abuse Clearance Index clearance. Based on today's inspection and observations, there are no deficiencies being cited at this time in accordance with Title 22, Division 6, Chapters 1, 5 and 6. A copy of this report was reviewed and given to facility representative, who the administrator Evelyn Preston authorized Jodi Lindsay House Manager. Exit interview conducted and a copy of this report was discussed and provided to Facility Manager on this date.


summary: Facility Evaluation

raw_content:
Narrative:
On October 29, 2024 at 11:25AM, Licensing Program Analyst (LPA) Adaleyci Caballero arrived at Wonderland of Choices Premier Services and met with House Manager Jodi Lindsay. LPA explained that the purpose of the visit was to interview a client, currently in their care, regarding this client's prior placement. A copy of this report was provided to Jodi Lindsay.

met_with: House Manager-Jodi Lindsay


summary: Facility Evaluation

raw_content:
Narrative:
On May 1st, 2025, at 10: AM Licensing Program Analysts (LPAs) Claudia Aguilera and Cynthia Ramos and Licensing Program Manager (LPM) Abdoulaye Traore arrived at Wonderland of Choices Premier Services Enhanced Behavioral Support Home to conduct a random annual inspection of the facility. LPAs and LPM were toured inside and out with House Manager Jodi Lindsay. There were two clients and nine staff including the house manager present at the facility during the inspection. The home was approved for two non-ambulatory clients and two ambulatory clients aged 6-18. The home is a one-story residence and consists of: · Bedroom #1 furnished with full bed size, a closet and storage space It sleeps a 12-year-old male client · Bedroom #2, furnished with a full-size bed, a closet and plenty of storage space. It sleeps a 16-year-old male client · Bedroom #3 furnished with full size bed, a closet and storage space it sleeps a 14-year-old male client · Bedroom #4 furnished with full size bed, a closet and storage space it sleeps a 12-year-old male client · A dining room with a large table, a furnished living room with no fireplace, a kitchen, a pantry, two walk-in handicap access full bathrooms, and the game room/activity area in the garage. All bedrooms were arranged so that no more than two children share a room, and there was one child per bed. No room was commonly used for other purposes other than a bedroom, and no bedroom serves as a passageway to another room. There were adequate drawer and closet space for children's belongings. The smoke and carbon monoxide detectors were checked and were working properly. The laundry room was located in the garage. The bathrooms were clean and in good repair. The hot water was measured to be F degrees. All hazardous items have been properly made inaccessible to areas where clients will have access. The kitchen had adequate cooking supplies and utensils. The medications were stored and locked in a cabinet in the kitchen. Cleansers/chemicals were locked and stored in the kitchen underneath the kitchen sink and additional cleaning supplies were in the garage. Sharp knives were inaccessible and stored in a locked cabinet in the kitchen. The First Aid Kit was located inside the cabinet in the kitchen and contained all required items. The living room area had a closet with age-appropriate games and activities. The garage had activity equipment for clients and laundry area. All windows and screens were in good repair. There were no guns or weapons in the facility as stated by House Manager. There were cameras in the common areas total 6 located in the office, living room and kitchen, two-hallways and outside. The following required posted items were observed accessible to clients: Grievance procedures, personal rights, ombudsman poster, visitation policies, and current menu. Clients' medications were observed to be inaccessible and stored in the kitchen cabinet. The medication logs were kept updated and the dispensing records had no discrepancies. LPAs and LPM observed a minimum of seven-day non-perishable and a three-day perishable supply of food. There was a variety of snacks available for clients as well. Two clients were interviewed and indicated that they feel safe in the home and accorded their personal rights. Additionally, four staff were interviewed. The facility outside grounds was also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. In the back yard, there was a locked swimming pool inaccessible to clients. The pool was surrounded by a wrought iron fence measured over 6 feet tall with a gate that self-latches and opens outward. The facility had an operable delayed egress and sprinkler systems. Clients' files were reviewed and following documents were present: Independent Behavior Support Plan, Individual Program Plan, health records, LIC 621 and medical consent. Staff records including current crisis prevention intervention (CPI), Registered Behavior Technician (RBT), First Aid and CPR were reviewed during the inspection. The facility emergency plan was also reviewed, and all staff had the Department of Justice and Child Abuse Clearance Index clearance Based on today's inspection and observations, there are no deficiencies being cited at this time in accordance with Title 22, Division 6, Chapters 1, 5 and 6. An exit interview was conducted and a copy of this report was discussed and provided to House Manager this date.

met_with: House Manager, Jodi Lindsay


summary: Facility Evaluation

raw_content:
Narrative:
On March 23, 2026, Licensing Program Analyst (LPA) Babatunde Aborchie arrived at Wonderland of Choices group home annual required - 2-year inspection. There were 4 clients in placement. The home was licensed to serve four (4) developmentally disabled children, two (2) non ambulatory only. Preferred to serve aged 6-18. The Facility was toured both inside and out with facility manager (FM), Jodi Lindasay. The home is a single-story building with four bedrooms, an office and two full bathrooms, both wheelchairs accessible. During the inspection, LPA observed the home consisted of a living room, an office, a dining area, a kitchen, pantry, storage, a garage, and four bedrooms. Bedroom #1 was furnished with a full-sized bed; it sleeps one ambulatory client. Bedroom #2 was furnished with full-sized bed; it sleeps one ambulatory client. Bedroom #3 was fully furnished with a full-sized bed; it has an exit door outside; it sleeps one non-ambulatory client. Bedroom #4 was fully furnished with a full-sized bed; it has an exit door outside; it sleeps one ambulatory client. Sharp knives were inaccessible and stored in a locked drawer in the kitchen. The First Aid Kit was in the kitchen cabinet and contained all required items. Medications were stored in a locked cabinet in the kitchen. The garage was inspected and used for storage, game area and laundry room. The water temperature was tested and measured at 115 degrees F. LPA observed a minimum of seven-day non-perishable and a three-day perishable supply of food. There was a variety of snacks available for clients. A trash can was observed to have tight fitting cover. The following required posted items were observed accessible to clients: personal rights, visitation policy, and current menu. The clients' medication log records were kept updated with no discrepancy. Four fire extinguishers were observed and operable. Cleansers/chemicals were locked in the cabinet by the laundry room in the garage. In addition to the space, there was an office, fully furnished with desks, computers, and office supplies. All bedrooms were arranged for one child per bed. No room was commonly used for other purposes other than a bedroom, and no bedroom serves as a passageway to another room. There were adequate drawer and closet space for each child's belongings. The smoke and carbon monoxide detectors were checked and working. All hazardous items have been properly made inaccessible to areas where clients have access. All windows and screens were in good repair. Facility manager stated that there were no guns/weapons in the home at this time. There was a total of six cameras, two located outdoors, and four indoors which met the title 22 camera policy. The facility outside grounds were also inspected and it was observed to be clean and well maintained. Emergency exits were free from obstruction. Four Clients' files and two staff files were reviewed and found to comply. One client and two staff interviews were conducted. Based on today's inspection and observations, there are no deficiencies being cited at this time. A copy of this report will be provided to the licensing program manager for final approval. An exit interview was conducted, and a copy of this report was discussed and provided to the FM, Jodi Lindsay.

met_with: Facility Manager


raw_content:
Narrative:
On September 29, 2025, Community Care Licensing (CCL) received a complaint alleging that staff (S2) hit minor (C1), staff inappropriately restrained minor (C1), staff threatened minor (C1), and staff does not accord privacy. It was specifically reported to CCL that C1 damaged property and was involved in an altercation with staff, which led to law enforcement being called and C1 being transported for further evaluation. It was reported that this behavior happened after C1 was hit by S2 and restrained. In addition, it was alleged that staff did not allow C1 to sleep properly and would wake C1, interrupting their rest, while in care. Although CCL received detailed information alleging a violation of C1's personal rights in care. LPA received inconsistent information that would support or deny that a violation of C1's personal rights occurred or did not occur in care as a result of the allegations. Records reviewed indicate that C1 had multiple behavioral incidents involving physical aggression and property destruction, which resulted in multiple law enforcement contacts while in care. Confidential interviews denied the allegations and reported that C1 was a primary aggressor, and staff acted accordingly in response to C1's behaviors in care. Confidential interviews further denied the allegation that staff did not provide C1 with privacy in care. Other confidential interviews stated that staff were not involved in any altercations with C1 and had never threatened C1. Based on confidential interviews, record review the allegation that staff (S2) hit a minor, staff inappropriately restrained a minor, staff threatened a minor, and staff does not accord privacy are unsubstantiated. The allegations may have happened or are 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 this report, along with the appeal rights, was provided to Direct Support Staff Lead, Jhonny Tivao.

Investigation Findings:
13On April 15, 2026, at 11: AM, Licensing Program Analyst (LPA) Cynthia Urena met with Wonderland of Choices Premier Services Group Home (GH) Direct Support Staff Lead, Jhonny Tivao to deliver the investigative findings regarding the above-stated allegations. On October 8, 2025, at 1: PM, Licensing Program Analyst (LPA) Babatunde Aborchie initiated the investigation at the GH. LPA Aborchie conducted a health and safety assessment of the GH and observed no immediate health and safety deficiencies. LPA Urena continued with the investigation on April 8, 2026, and collected pertinent documents from the GH staff and client files to assist with the investigation. Interviews were conducted with three staff members (S1, S2, and S3) and one client witness (C2). LPA attempted to interview an additional client witness (C2), but C2 declined to be interviewed. LPA also attempted an interview with C1. However, due to C1's unknown whereabouts, an interview was not conducted. In addition, LPA Urena conducted a record review to further assist with the investigation. (**Continued on the next page**) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: WONDERLAND OF CHOICES PREMIER SERVICESFACILITY NUMBER: VISIT DATE: 04/15/2026

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

met_with: Direct Support Staff Lead,Jhonny Tivao


facility_name: YAI CARSON WOODS RD EBSH

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Wendy Brown conducted an announced Pre-licensing inspection on 02/14/2025, arriving at the facility at Carson Woods Road in Fortuna, California at 9: AM. The licensure application is for an Enhanced Behavioral Supports Home (EBSH) with a capacity of four clients male and/or female ages 12 through 17 years. LPA met with Cheryl Karran, LSW - Regional Director, Melissa Koren, QBMP and Ann Martin, Administrator. During the pre-licensing visit, LPA conducted a Health and Safety inspection using the CARE tool. INTERIOR: LPA observed that the facility is a single-story residence with four client bedrooms. Sufficient storage space for client's personal belongings was observed in each room. No food was observed as there are no clients, and no pending placement at this time. Facility will verify required food on hand at time of client placement. LPA observed the facility was clean and safe inside and out. The facility has four bedrooms, a family room and separate living room, kitchen, dining area, sensory room, laundry room, two staff offices, a med room, laundry room, an activity area, and two bathrooms. Extra effort is made to prevent damage from clients who may have escalated behaviors to include weighted chairs too heavy to throw, triple sheet-rocked walls, and doors with piano hinges. There are two bathrooms in the facility that are accessible and available for client use. The water temperature was tested and found to be 109 degrees. Continue on 809c Appliances throughout the facility are new including those in the kitchen and the washer and dryer in the separate laundry room. YARD: LPA observed the back yard of the facility to be sloped, tiered and a fenced yard with a cement slab at ground level. There's a fence at the rear of the property leading to a trail in the forest behind the property. The front yard has a garden area and parking with a circular driveway. The front is fenced but has unlocked walk-through gates allowing pedestrian access in and out Both yards are well maintained. SECURE AND SAFETY ITEMS: LPA observed a staff office space that is locked and inaccessible to clients, where client records will be retained. LPA observed a refrigerator and locked medication cabinet in the locked "med room". Emergency exits and evacuation plans are clearly marked. Smoke and carbon monoxide detectors were throughout the home, were tested and found to be functional during the inspection. Fire extinguishers were present with an expiration date of 11/28/2027. LICENSURE: Appropriate documentation has been received by the Department. As this will be a new facility, several required items were ordered and verification of those items being in place will be provided to LPA before a license will be issued this EBSH facility. A signed copy of this report was provided to Administrator and Regional Director. END.

met_with: Cherly Karran, Regional Director


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Wendy Brown conducted an unannounced post-licensing inspection on 7/25/2025 at 10: AM at the above location, as required for the Enhanced Behavioral Supports Homes (EBSH) licensure. LPA met with Administrator Steven Toal. The EBSH has a capacity of four clients male and/or female ages 12 through 17 years. During the post-licensing visit, LPA conducted a Health and Safety inspection using the CARE tool. LPA observed the facility was clean and safe inside and out as was previously observed during the pre-licensing inspection. The few items missing at the time of the pre-licensing inspection were accounted for and observed by LPA. The outside of the facility is fenced and includes a garden area in the front and a patio in the back. LPA observed client bedrooms, equipped with appropriate furniture, bedding, and supplies for clients. Sufficient storage space for client's personal belongings was observed in each room. One client is currently in placement. LPA observed the medication stored and locked in a locked office in a locked filing cabinet. The kitchen area was equipped with needed supplies. LPA observed two days of perishable food and seven days of non-perishable food on site. LPA observed a staff office space that is locked and inaccessible to clients. Client and staff records are locked. The facility has an outdoor shed used for maintenance supplies and is locked and made inaccessible to clients. The laundry room does have an unlocked door for client and staff access, but all cleaning supplies and chemicals are locked up high in cabinets. Report continued on 809- C The smoke and carbon monoxide detectors are functional and there is a fire sprinkler system in the facility. Fire extinguishers were present and service was current. A fully equipped first aid kit was in the laundry room. LPA observed the following items posted: license, personal rights, emergency disaster plan/contacts, exit signs, and the facility sketch with emergency exit routes identified. There are two bathrooms in the facility that are accessible for client use. LPA conducted four staff interviews and one client interview. LPA reviewed five staff files and one client file. This facility meets Interim Licensing Standards mandates and is clean safe, sanitary and in good repair. LPA recommends the facility obtains permanent license with management approval. A signed copy of this report was provided to the Administrator via email.

met_with: Steven Toal, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 08/21/ Licensing Program Analyst (LPA) Lyta Vue arrived unannounced at the facility and met with Administrator (ADMIN) Derrick Buchanan. LPA Vue conducted a Case Management to conduct a client file review and did a Health and Safety Inspection. During the post-licensing inspection by LPA Wendy Brown the client had very recently been placed at the facility and the file had not been completely established. LPA Brown was advised that the client's representative had not been responsive in providing needed information and Medi-Cal information was pending to establish local care providers for the client. LPA Vue used the Client Records portion of the CARE Tool in conducting the file review. LPA Vue observed there to be no deficiencies at this time. An exit interview was conducted A sign copy of this LIC-809 was provided to Derrick Buchanan

met_with: Administrator (ADMIN) Derrick Buchanan


summary: Facility Evaluation

raw_content:
Narrative:
On 11/04/25, Licensing Program Analysts (LPAs) Kellie McKinley and Lyta Vue arrived unannounced at the facility and met with Derrick Buchanan, Administrator (ADMIN). The purpose of the visit was to conduct a Required Annual Inspection of the facility. The facility is new and this is their first Annual Inspection. LPAs utilized a copy of the CARE Tool to complete the Annual Inspection as the inspection tool would not load for this visit type. The facility is licensed to provide treatment services for ambulatory and non- ambulatory children ages 12 through 17 years. The facility currently has one (1) client, and takes client from the regional center. One (1) client were present during the inspection but refused to be interviewed. The facility is licensed for a maximum capacity of four(4). Staff to client ratio 2:1. LPA's conducted an inspection of the physical plant and checked for all necessary requirements. The facility had no noticeable odor and maintained an acceptable room temperature. There is a total of four (4) bedrooms available for clients, with each client having their own bedroom. LPA's observed the client bedrooms, common rooms, kitchen, two (2) bathrooms, the backyard, and the staff office to be clean and organized. The facility has no garage but several storage areas. LPA's observed each client's bedroom to have a closet, a dresser, and a clean mattress. Sheets, blankets, and pillows were in good condition. Every bedroom was decorated with the client's personal items. LPAs observed a locked staff office where files and medications are stored. Client files were stored in a locked cabinet in a locked office. Annual Report continued on 809c LPAs observed the proper postings including facility license, complaint hotline, menu, and emergency disaster plan. Smoke alarms were in working order, fire extinguishers were current and will expire September 2026, and a first aid kit was fully stocked. The facility has no outstanding fees. LPAs observed 2 days of perishable food and 7 days of non-perishable food in the kitchen and in the additional refrigerator in the kitchen. Disinfectants and cleaning solutions were inaccessible. LPAs reviewed five (5) client files. With five (5) client files reviewed, no clients were taking court ordered psychotropic medications. Clients were current on CHDP physical exams and dental exams. The client's Needs and Services Plan were complete and up to date. LPAs reviewed five (5) staff files. Staff files had completed criminal record clearances, and all required initial and annual training. First Aid and CPR certifications were up to date for all staff. Administrators Certificate was valid. LPAs interviewed three (3) staff on site. LPAs interviewed three (3) clients. No citations were given on this date. A signed copy of this LIC-809 and LIC-809C was provided to Pat Sweeney, Administrator. An exit interview was conducted. End of Annual Inspection report.

met_with: Derrick Buchanan- Administrator


facility_name: YAI EAST TABOR AVE.-ENHANCED BEHAVIORAL SUPPORTS

raw_content:
Narrative:
Based upon 6 confidential interviews and a review of the records, there is documented information provided regarding timely work orders for the damage caused to the facility including the windows in question. The facility is required to use a specific company to address damage that is significant like broken windows and doors. Although communication could have been better, it is unknown as to whether that would have prompted the State appointed contractor to address the repairs sooner. Regarding the issue related to the client receiving medication in a timely manner, documentation indicates the client was complaining of cold like symptoms on 3/13/23 but was ambivalent about going to a doctor for treatment at that time. Documentation is not clear as to when the client was seen by a doctor, but there were a couple of attempts to get treatment from a provider and to offer to get treatment for the client. The client refused a couple of times and one urgent clinic refused to see the client. The client did receive over the counter medications to treat the cold symptoms starting on 3/13/23 and ending on 3/16/23 with a medical providers prescription in place. It is possible that other options may have resulted if the client received medical treatment sooner, like seeking a telehealth appointment. The allegations are determined to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to provide the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Investigation Findings:
UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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

met_with: BCBA


summary: Complaint Investigation - Unsubstantiated - 2 deficiencies - 1 allegation

raw_content:
Narrative:
Although the allegation 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 allegation is Unsubstantiated. An exit interview was conducted. A copy of this report was provided to Lead RBT, Kristen Fox LPA reviewed the schedule for the month of December 2023 and learned that on December 3, 4 and 5, 2023, the facility had three staff members that were working in the AM shift (See LIC 9099D). Furthermore, LPA reviewed a Special Incident Report (SIR) that was submitted on October 26, 2023 to the Regional Center Placement Agency from the facility that reflected a staff member leaving a client alone at a local hospital. LPA conducted an interview with the Case Manager on December 12, 2023 which confirmed that the client was left alone at a local hospital while staff went back to the facility (See LIC 9099D). 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(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Chapter 5, are being cited on the attached LIC 9099D. Exit interview was conducted, and a copy of this report along with appeal rights were given to the Lead RBT, Kristen Fox.

Investigation Findings:
13On January 22, 2024 at approximately 02: Licensing Program Analyst (LPA) Farhaan Sarangi arrived unannounced at YAI East Tabor Ave.-Enhanced Behavioral Supports and met with Lead RBT, Kristen Fox for the purpose of delivering findings. During the investigation, LPA Sarangi reviewed the facility file, client records which includes the Individual Program Plan (IPP), Needs and Services Plan, staff records including the complaint history and facility incident reports. LPA Sarangi conducted interviews with staff, clients and an outside placement agency. Based on interviews conducted during the investigation process the allegation above cannot be substantiated because there were inconsistent statements made throughout the course of the investigation process. In addition, there were no witnesses confirming that the facility staff left minors alone in the facility without supervision. (Report continued on LIC 9099C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Farhaan Sarangi 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 SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: YAI EAST TABOR AVE.-ENHANCED BEHAVIORAL SUPPORTSFACILITY NUMBER: VISIT DATE: 01/22/2024

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

Deficiencies:
84065.51: Licensee shall submit a staff schedule for the next eight weeks reflecting which staff members are going to be on duty. Furthermore, Licensee shall go through staff training and submit a plan for future compliance. Licensee shall also submit an LIC 9098 understanding of the staff/child ratios.
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80065: Licensee shall submit a staff schedule for the next eight weeks reflecting which staff members are going to be on duty. Furthermore, Licensee shall go through staff training and submit a plan for future compliance. Licensee shall also submit an LIC 9098 understanding of the regulation.
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met_with: Lead RBT, Kristen Fox

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784065.5	Staff/Child Ratios

(c)	If the children require special care and supervision because of age, problem behavior or other factors, the number of on-duty child care staff shall be increased.

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Personnel Requirements

(a)	Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.1
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summary: Complaint Investigation - Unsubstantiated - 1 deficiency - 1 allegation

raw_content:
Narrative:
"AMENDED" This is an amended version of the original report created on January 25, 2024- SEE BELOW. LPA learned that the time when medications are dispensed could be off due to poor signal while dispensing. During a review of the internal investigation report conducted by the facility and the incident report forwarded to the Regional Office, LPA learned that the Former Staff Member use to fall asleep during work shifts and the minors were left unsupervised for an extended period which presented conduct inimical as it relates to the Former Staff Member. The internal investigation report noted that during one incident, the Former Staff Member was caught sleeping on the couch. Since the incident, the Former Staff Member was terminated due to the incident and conduct. In addition, during interviews, LPA learned that the facility has been going through staffing issues and that the facility needs staff. 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(s) are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 5, are being cited on the attached LIC 9099D. Exit interview was conducted and a copy of this report along with appeal rights were provided to the Licensee/Regional Director.

Investigation Findings:
13"AMENDED" This is an amended version of the original report created on January 25, 2024-SEE BELOW. On January 25, 2024 at approximately 09: AM Licensing Program Analyst (LPA) Farhaan Sarangi arrived unannounced at YAI East Tabor Ave.-Enhanced Behavioral Supports and met with Lead RBT, Kristen Fox for the purpose of delivering findings. During the investigation, LPA Sarangi reviewed the facility file, client records which includes the Individual Program Plan (IPP), Needs and Services Plan, staff records including the complaint history and facility incident reports. LPA Sarangi conducted interviews with staff, clients, and an outside placement agency. Based on an observation of the internal investigation document conducted by the facility, LPA learned that a staff member made an error on dispensing medications. Furthermore, during observation of the Medication Administration Record (MAR), (Report continued on LIC 9099C) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Farhaan Sarangi 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 SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: YAI EAST TABOR AVE.-ENHANCED BEHAVIORAL SUPPORTSFACILITY NUMBER: VISIT DATE: 01/25/2024

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

Deficiencies:
80065: (a)	Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
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14

met_with: Lead RBT, Kristen Fox Licensee, Cheryl Karran

title: Personnel Requirements


raw_content:
Narrative:
LPA Sarangi conducted a Medication Administration Record (MAR) review on March 11, 2024, a subsequent review on March 18, 2024, and observed that both client medication lists were reviewed along with the clients Medication Administration Record (MAR). Both client MARS were observed to be appropriate during the said reviews. Furthermore, during a tour of the facility Medication Room on March 11, 2024, and March 28, 2024, LPA observed medication carts were secured and locked and no evidence of medication being on the floor or pre-filled. Although the allegation may have happened is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted, a copy of this report and the Appeal Rights were provided to Lead RBT, Kristen Fox.

Investigation Findings:
13On April 2, 2024 at approximately 01: PM, Licensing Program Analyst (LPA) Farhaan Sarangi arrived unannounced at YAI East Tabor Rd. Behavioral Supports for the purposes of delivering complaint findings. LPA met with Lead RBT, Kristen Fox and was granted access into the facility. During the investigation, LPA Sarangi reviewed the agency's file at the licensing office, including the complaint history, criminal background check and facility personnel report summary. LPA conducted a Medication Administration Record (MAR) review, interviewed staff members and one client, but second client denied being interviewed. Based on interviews conducted, the allegation above cannot be substantiated because there were inconsistent statements made throughout the course of the investigation process. LPA could not obtain corroborating evidence that staff are mismanaging children's medications. (Report continued on LIC 9099C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Farhaan Sarangi 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 SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: YAI EAST TABOR AVE.-ENHANCED BEHAVIORAL SUPPORTSFACILITY NUMBER: VISIT DATE: 04/03/2024

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


raw_content:
Narrative:
Based on interviews conducted during the investigation process the above allegations cannot be substantiated because there were inconsistent statements obtained from current and former staff. Records reviewed, and an Individualized Behavior Support Plan for the minor in care dated November 16, 2023, reported that C1 was receiving services to include behavior health, trauma informed care, verbal de-escalation, and an emergency intervention plan. C1 had access and received food service, leisure, and community outings. It was also reported that the facility does not have enough staff to provide care and supervision to minor(s) in care. During records review, it was documented that C1 required 1:1 supervision while at the hospital and 2:1 supervision at the facility. C1 was admitted to the hospital in November 2023, hospital staff called the facility when C1 was due to be discharged but were unable to pick C1 up due to no staff being available. It was reported that the facility was leaving C1 at the hospital because they might not have staff to care for C1 during the weekends. LPA Stiger was not able to confirm if staff was not available to pick up C1, but interview statements obtained indicated that the facility has had Administrator changes but was fully staffed and current staff will pick up shifts as needed. Lastly, LPA Stiger was not able to obtain supportive information from C1 or C2 because they were distracted with their electronics and not engaging with LPA during the interview process. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview conducted with Lead RBT, Kristen Fox. A copy of this report and the Appeal Rights were provided to the facility.

Investigation Findings:
UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
Four out of the four interviews conducted confirmed that staff handled minor in a rough manner causing injury and staff are not providing a comfortable environment for minor did not occur. During the interviews LPA Turner was informed by the client in care that they initiated the altercation and expressed a desire for the staff member to retaliate physically. The staff member made clear efforts to avoid engaging in any physical confrontation and attempted to de-escalate the incident. The staff member tried to run away and distance themselves from the client. It was confirmed by another staff member present that the staff involved sustained minor injuries further demonstrating that they did not try and fight back. The client in care stated that they are struggling with their behaviors and the change in environment was hard at first. The client stated they are feeling better in the home and are working on strategies to better themselves. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report and the Appeal Rights were discussed and provided to the licensee.

Investigation Findings:
13On June 4, 2025 at approximately 11: AM, Licensing Program Analyst (LPA) Zaria Turner made an unannounced visit to deliver findings to the above facility and met with Imanya Anderson, Lead Registered Behavior Technician LPA Turner was given permission by Assistant Program Administrator, Lanesha Devers, to have Imanya Anderson, Lead Registered Behavior Technician to sign off on all reports. Prior to the meeting LPA Turner initiated the complaint investigation on March 12, 2025. No deficiencies were cited during that inspection. LPA Turner requested the following documents: Staff and Client Roster, Staff Schedule, Staff Contact Information, a Client Face Sheet, a Job Injury Form, Photos, copies of Emails, and a Needs and Services Plan for one client in care. LPA Turner conducted four interviews between March 12, 2025 and May 29, 2025. Based on evidence obtained and confidential interviews conducted during the investigation process the above allegations cannot be substantiated because there were inconsistent statements throughout the investigation process. Report continued on LIC 9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Zaria Turner 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 SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: YAI EAST TABOR AVE.-ENHANCED BEHAVIORAL SUPPORTSFACILITY NUMBER: VISIT DATE: 06/04/2025

Allegations:
- UnsubstantiatedEstimated Days of Completion:
- Unsubstantiated Estimated Days of Completion:
- Unsubstantiated Estimated Days of Completion: 90


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst, (LPA) Tana Kinder conducted a pre-licensing, Component II meeting with Cheryl Karran on 2/3/2022 to review revision requests to the program design. The meeting was conducted using the video conference platform, Microsoft Teams. Section 3: Every box was checked. Do you truly see this program serving every type of need identified on the list? Have you had experience and training with every population identified? Section 4: Page 2: Other descriptions, for example, behavioral and/or medical assessments? NSP & IPPs. Page 5, Line 9: remove comma after Regional Center Staff. Page 5: includes Long Beach Aquarium as a possible activity, please remove and identify specific options in your area- what is in your community? Give names and locations of dining places, parks, gyms; etc. Page 6: Note: and parent- check with them also. Line 31 the sentence starts with "Ways." Line 32 ...not limited to (should not have colon(:). Line 33 as support (insert regulations) to the person's needs. Line 36 codes and regulations. Line 39 ensuring. Page 7: Under dating line 5 physicals written 2# 5. Page 9: Please refer to local activities. Page 10: Are these optional? Aroma and meditation. Continued... Section 5: Lists services for San Joaquin and Solano county. Also make sure the programs listed are available to Regional Center clients-use examples of vendored services if applicable. Section 6: Page 15: top- will family or legal guardian also be informed and included? Page 15, Line 3: Individual(s) *Attach a copy of the appointment history tracking form to this section. Page 16: First Aid Kit-you list some specific items. Make sure you have everything required by regulations. Page 17, 2nd paragraph, line 5: Add PMAR with MAR. 2nd paragraph, last sentence: Be specific-where are you going to store? Have a designated area assigned. Page 20: Expired Medication Disposal- Change locations to local area. Section 7: Page 21, line 1: Define vigorous background check. 2nd sentence vigorous. *If you use volunteers add information here regarding driving policy. *Address potential use of car seats or car restraint systems for younger/smaller clients. Section 8: Individual move-in agreement: Page 23, Bullet 7: What age group? Be more specific. Page 26, Initial Screening: Will you take county referrals or only Regional Center? Later it says only Regional Centers. Clarifying would provide consistency. Page 28, Line 2: "individuals (who) are..." Under admission meeting documentation: please add Personal Rights will also be reviewed and a copy will be provided (unless I missed where you cover that). Page 29: Will you be taking CSEC clients? Continued... Section 9: Page 32, Bullet 2: remove the period (.) after the word following and perhaps use a colon (:) after "the plan of operation:" since you are listing the following information. Page 36, Line 1: remove the period (.) after "Individual Behavior. Supports..." Page 36: Who is responsible for completing the IBST? Section 10: Provide a detailed policy/procedure for removal of youth. Have a copy of the discharge plan/policy that would be signed by the parent/guardian in the child's record in this section. Section 11: When are visits allowed? Are the designated times/days visits happen or times they do not happen (during groups at the facility, etc.)? Section 12: Please address: Curfews, dress codes, dating policy, completing homework (?). Gambling and betting?? Why is Personal Hygiene addressed here? There is nothing that says anything about rules in the narrative. Maybe Section 9? Section 14: Page 44: Why is that first (very long) sentence in this section? What are you trying to convey? Maybe it should be rewritten and put in Section 3? Page 44, Line 8, last word: Avoid(s), remove (s). Line 14: "When an individual is safely (restrained) no restraint. Line 16: "simultaneously are restraint" should be "are simultaneously restrained." Page 45, paragraph 5, line 3: the last word, advise(d), paragraph 6, 1st sentence does not make sense. Already involved in Criminal Justice or preventing Criminal Justice involvement or additional Criminal Justice involvement? Continued... Section 15: Incident Report Section, Bullet 1: Individua(l)'s Section 16: Do you have a grievance form for the client's to access? Will you document the process if a client initiates a grievance? Where will this be kept? Section 17: Please edit the Policy and Procedures for Handling Children's Funds to reflect a minor. For example, remove the examples that do not apply to children; tax credits, renter credit, gambling winnings, etc. Include parents in this section as it applies. Page 56, Bullet 8: remove cigarettes and perhaps some of the other examples listed on page 56 and 57 as they do not pertain to minors. Please address allowance and how that will be handled. Section 18: Page 61, 2nd paragraph, line 3: sense (of) ownership. Are there paid chores? Section 19: Page 62, 2nd paragraph, line 2: Individuals is (are). Last ling page 63: fitting (fit). Page 64, Bullet 6: similar substance is (will). 2nd Bold/underlined section: "If at any point the dishwashing machines ... staff is (are). Section 20: Bullet 1, line 3: Rapidly change(s). Last bullet, line 1: "to be spend, (spent). Continued... Section 21: What is peer partner position? If you don't have it, do you want to eliminate? Otherwise, elaborate regarding the parameters for this position, including training, background check, etc. Should this be in Section 26? Section 22: QBMP/BCBA: "Several years of writing reports," be more specific; 2-3 years? 3-4 years? Page 72, line after paragraph 3: "The success(ful) candidate must..." Section 22, 23 and LIC 500: Be consistent with job titles: Administrator/Program Administrator, RN/RN Consultant, etc. Section 24: Where will you track and keep documentation for each employee's training. Add this information. Section 25: Don't see Appendix VII, specifically LIC 309. Section 26: Should Peer Partners be included here? Where will you keep track of volunteer training? Section 27: Provide a copy of the lease. Sections 28: Please identify where the Main Shutoff Valve is located. Section 29: Please provide Board of Directors information. Continued... Appendix II: Page 1, under Policy: "Upon admissions..." Page 1, last paragraph, line 4: "and so for(th)." Or so on?? Line 5: "developed by and DDS," Page 2, Line 6: regarding a restraint not lasting longer than 10 minutes: How was that timeframe determined? If the client is still escalated, how will you end the restraint? Page 2, line 8: "child is safely restraint (restrained)." Page 2, Multiple Emergency Interventions: How do you determine adequate number of staff? In the training handbook, is there a minimum number of staff that are required? Do you need to take the size of the client and staff into consideration? Maybe defer to the protocol of the technique you are using and document that here. Page 2, last paragraph, line1: "or a compliant (complaint)." Page 3, Debriefing, Bullet 1: "Child who was restraint (restrained). Bullet 9: "Determining where (if)..." Page 4, paragraph 2, line 1: "CCH will report to the Department..." is the Department DDS, DSS or both? CCL? Appendix III: Financial Policy Page 1, paragraph 4, line 4: individual(')s file Page 2: Where is the bonding documentation kept? *This appears to have been written for an adult client population. Please review and revise for minors and their parents and/or representatives like CPS. There is policy regarding loans, paycheck stubs, etc. Is any amount of $200 going to be returned to the client's parent or representative? Page 9: The list needs to reflect minors. Same with page 11 list of disallowed expenses.

met_with: Cheryl Karran


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Tana Kinder conducted an announced pre licensing inspection with the Administrator, Qualified Behavioral Modification Professional (QBMP) and Director of Residential Services on 7/28/2022 at 10:30 am at the facility. LPA conducted the walk through of the facility with the above named staff and observed 4 bedrooms, 1 garage, 2 common areas, 2 bathrooms, a kitchen, laundry room, sensory room and a locked medication room. All spaces were clean, sanitary, free of insects, and had unobstructed pathways. LPA observed 7 days' worth of non-perishable, food for 4 potential clients. The refrigerator was 39 degrees and the freezer was 0 degrees. The hot water from the kitchen sink was 106.8 degrees. The facility does not utilize protective separation rooms. All the bedrooms are furnished with a bed, dresser, nightstand, desk/chair, closet and is well-lit. The front yard and back yard are fenced in with an accessible gate to the front of the property. The grounds have a recreation area with a basketball hoop and plenty of space for activities. No cameras are in use in the facility. There is a backup located on the side of the property. The water source is county water. The water sprinkler system is located on the side of the house. There is a locked storage structure in the enclosed part of the backyard. The backyard is fenced off with extra yard on the other side that is not accessible to the clients at this time. On the other side of the locked backyard there are 2 unlocked sheds, and 2 horse stable structures that are not in use or accessible to the clients. The facility is using a monthly rental minivan to transport clients. There are 24 staff associated to the facility. There are currently no clients at the facility. Continued... LPA has observed the following that need to be brought into compliance before issuance of the license. 1. Hygiene products need to be purchased and available for 4 clients. 2. Mattress pad covers for (4) beds. 3. Laundry detergent in the laundry room. 4. Facility Sketch needs to include the whole property and all dwellings. 5. The access to the side yard will be made in accessible like the rest of the outer backyard. 6. The ditch on the outside of the fenced front yard will be filled or secured so it is inaccessible. LPA reviewed the following forms with the facility staff: An exit interview was conducted and copy for the report was provided.

met_with: Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On May 5, 2026 at approximately 2:00pm Licensing Program Analyst (LPA) Tatyana Shulz made an unannounced case management inspection at the above Enhanced Behavioral Support Home and met with Assistant Administrator, Lanasha Devers who assisted LPA Shulz with the inspection. The purpose of the inspection is to follow up on an Incident Report that was received by the Department on April 29, 2026, involving lack of supervision. LPA conducted 1 staff interview and 1 client interview during this inspection and obtained the following documents: Staff schedule for April 2026 and the most up to date staff contact list. This case management will remain open. Further investigation is need. Exit interview conducted and a copy of this report will be sent to the licensee.

met_with: Lanasha Devers-Assistant Administrator


facility_name: YAI MORRO RD. EBSH

raw_content:
Narrative:
Confidential interviews did not believe the interactions was due to lack of supervision, however, other confidential interviews did not provide consistent statement of the alleged events. LPA received a conflicting information. Based on confidential interviews, the allegation that due to lack of supervision, inappropriate sexual interactions between C1 and C2 occurred, may have occurred, however, there was not a preponderance of evidence to support or deny the allegation. Therefore, the above allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this signed report was provided to Portia Tresvant, Administrator.

Investigation Findings:
13On March 20, 2024, at 9: AM, Licensing Program Analyst (LPA) Lucero Jauregui conducted an unannounced complaint inspection and met with Portia Tresvant, Administrator. The purpose of the inspection is to deliver the finding for the above allegation. LPA conducted an inspection of the facility on December 6, 2023, and one deficiency was noted. During the investigation, LPA conducted five staff interviews (S1, S3-S6), two client interviews (C1 and C2) and obtained incident narratives. On December 6, 2023, Community Care Licensing (CCL) received the allegation that due to lack of supervision, inappropriate sexual interactions between minors occurred. Confidential interviews indicated staff intervened with Ukeru pads when staff witnessed inappropriate interaction between C1 and C2. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: LUCERO JAUREGUI 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: Yai Morro Rd. EBSHFACILITY NUMBER: VISIT DATE: 03/20/2024

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

met_with: Portia Tresvant, Administrator


raw_content:
Narrative:
Confidential interviews did not produce information to corroborate the allegation, and the investigation did not reveal any there were no other witnesses to the alleged event. Based on confidential interviews, the allegation that S2 and S3 handled C1 in a rough manner, may have occurred or is valid, however, the allegation is not supported, or proven by evidence. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this signed report and appeal rights were provided to Portia Tresvant, Administrator.

Investigation Findings:
13On July 24, 2024, at 1: PM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Portia Tresvant, Administrator to discuss the investigative finding for the allegation noted above. LPA Jauregui conducted an inspection of the facility on January 26, 2024 and no deficiencies were noted. During the investigation, LPA Jauregui interviewed nine staff (S1-S11), one client (C2), and LPA attempted to interview Client 1 (C1), however, C1 is non-verbal. LPA obtained C1's Individual Behavior Support Plan, and staff schedule. On January 24, 2024, Community Care Licensing (CCL) received an allegation that staff (S2 and S3) handled minor in a rough manner. It was reported that C1 became physically aggressive towards S1, and S2 and S3 stepped in to assist, and S2 and S3 grabbed C1 by their wrists and ankles.Confidential interviews yielded that staff have not observed S2 or S3 be aggressive towards C1. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI 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: Yai Morro Rd. EBSHFACILITY NUMBER: VISIT DATE: 07/24/2024

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


summary: Complaint Investigation - Substantiated - 3 allegations

raw_content:
Narrative:
Confidential interviews and record reviewed also indicated that the facility is out of ratio when there are three staff present for two clients, as 1:1 supervision is not safe due to the behaviors of clients in care. Confidential interviews indicated the facility struggles with meeting staffing ratio, and staff are called in for coverage when needed. Record reviewed reflected that during the week of January 15 through January 19, 2024, the facility was out of ratio during the hours of 2: PM to 10: PM. Additionally, the facility was out of ration on January 15, 2024 and January 19, 2024 during the hours of 10: PM to 6: PM. Based on confidential interviews and record review, the allegation that facility was out of ratio is SUBSTANTIATED because the preponderance of evidence has been met. This posed a potential Health, Safety, or Personal Rights risk to children in care. The facility will be cited for violating Title 22, Division 6, Chapter 1, Article 06. Continuing Requirements, Responsibility for Providing Care and Supervision 80078(a), [See LIC 9099D]. An exit interview was conducted, and a plan of correction was developed with Portia Tresvant, Administrator. A copy of this report and appeal rights were provided to Portia Tresvant, Administrator.

Investigation Findings:
13On July 24, 2024, at 12: PM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Portia Tresvant, Administrator to discuss the investigative findings for the allegation noted above. LPA Jauregui conducted an inspection of the facility on January 26, 2024 and no deficiencies were noted. During the investigation, LPA Jauregui interviewed seven staff (S1-S6, S10), one client (C1), and LPA attempted to interview C2, however, C2 is non-verbal. LPA obtained C1's Individual Behavior Support Plan, level of supervision chart, staff schedule and Client Activity notes dated January 2024. On January 22, 2024, the Department received an allegation that the facility was out of ratio. It was reported that the facility was out of ratio during the week of January 15 through January 19, 2024. Confidential interviews and record reviewed indicated the required ratio was is 2:1 for each client (C1 and C2). SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: LUCERO JAUREGUI 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: Yai Morro Rd. EBSHFACILITY NUMBER: VISIT DATE: 07/24/2024

Allegations:
- SubstantiatedEstimated Days of Completion:
- Estimated Days of Completion:
- Estimated Days of Completion: 0