summary: Facility Evaluation

raw_content:
Narrative:
On December 15, 2021 at 9: AM Licensing Program Analysts (LPA) Isabel Mendoza made an unannounced annual/required visit. LPA met with Victoria Valencia, and Jordan Gonzales. The facility currently has 10 clients in care. At 9: AM LPA toured the facility inside and out and found the facility to be safe, clean and in good repair. All passageways are unobstructed. All smoke detectors are in working order. There are no firearms on the property. The fire extinguisher has been checked and is up to date. There are no bodies of water on the property. The facility is maintained at a comfortable temperature at 69 degrees. LPA recorded water temperature at 109 degrees. LPA inspected the medication storage and administration records and observed that the logs were complete and matched the stored medications. LPA left a copy of LIC A and B to ensure the facility includes all required items on their MARs. At 10: AM LPA Mendoza reviewed all 10 client files, and each file was complete. LPA reviewed 10 staff files and all files were complete and has all required items and training. LPA Mendoza requested the facility to start filing all training materials that is through Relias/online portal. LPA Mendoza was unable to interview staff and clients during todays inspection. No deficiencies cited during todays inspection. The facility received one technical advisory notes. Exit interview was conducted and a copy of the report was left with the facility.

met_with: Victoria Valencia and Jordan Gonzales


state: CA

facility_name: CASA DE AMPARO

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Based on interviews and record reviews the allegation that due to lack of supervision C1 choked C2, may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. Appeal rights explained, and a copy of this report was emailed to Erin Gospodarec for signature. Original signature on file.

Investigation Findings:
13On June 7, 2021 at 2:00 pm, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted a tele-inspection due to COVID 19. LPA contacted Erin Gospodarec to discuss the investigative findings for the allegation listed above. LPA Nicole Strickland conducted a tele-inspection on January 26, 2021 at 03:08 pm. Three of three children (C1, C2, C3) four staff, county social worker and program director were interviewed. It was reported to Community Care Licensing (CCL) that due to lack of supervision C1 choked C2. Confidential staff interviews reported that C1 and C2 were in the bathroom with the door open trying on hair wigs. Confidential staff interviews reported that once staff became aware of the incident, C1 went absent without leave (awol) from the facility. Additional staff interviews reported that when C1 returned to the facility C1's supervision was increased. Confidential interviews reported that C1 was kidding/playing around and did not choke C2 but it appeared as if C1 did choke C2. LPA was not provided any other specific details or decisive information regarding the alleged allegation that would confirm whether or not the allegation occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz 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 CCLD Regional Office, FACILITY NAME: CASA DE AMPAROFACILITY NUMBER: VISIT DATE: 06/07/2021

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

report_type: Complaint Investigation

met_with: Erin Gospodarec

complaint_status: unsubstantiated


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Confidential interviews reported that when C1 was placed at the facility C1 did not have a cell phone but had access to a phone in the cottages. S1 and LPA made several attempts to interview C1 but C1 refused to be interviewed. The interviews that were provided to the LPA were not consistent and did not provide any further specific details regarding all of the alleged allegations listed above. Based on interviews and record reviews the allegations that S1 engaged in an inappropriate relationship with C1, staff made inappropriate comments and did not treat C1 with respect and staff denied C1 access to the phone, may have occurred, however is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Erin Gospodarec.

Investigation Findings:
13On October 22, 2021 at 10:00 am, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an inspection at the facility and met with Erin Gospodarec. Special Investigator (SI) Annette Renquist of the Community Care Licensing Investigative Bureau completed the investigation. LPA Ann Valenzuela toured the facility on March 18, 2021 at 1:00 pm and reviewed all of the client files and facility files. Three of four clients, county social workers, three facility staff (S1, S2, S3) and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that S1 engaged in an inappropriate relationship with C1, staff made inappropriate comments and did not treat C1 with respect and staff denied C1 access to the phone. Confidential staff interviews reported that once C1 was discharged from the facility C1 contacted S1 with the encouragement of C1's social worker but S1 was not communicating effectively with S1's supervisor. Additional confidential interviews reported that no inappropriate boundaries were crossed between C1 and S1. Additional confidential interviews reported that staff did use correct pronouns when addressing C1. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Darlene Almaraz 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 CCLD Regional Office, FACILITY NAME: CASA DE AMPAROFACILITY NUMBER: VISIT DATE: 10/22/2021


raw_content:
Narrative:
Confidential interviews revealed that the facility had a ratio of one staff to eight clients for the period of one and a half hours, however, was the first time they have witnessed this ratio. Other Confidential interviews revealed that the facility is staffed per the facility program statement. Confidential interviews could not confirm or dispute that the facility is out of ratio. Based on interviews conducted and evidence gathered during the investigation, the allegation that the facility is out of ratio may have occurred, however is not supported, or proven by evidence. Therefore, the allegations are unsubstantiated at this time. A copy of this report, LIC 811, and appeal rights were reviewed and explained to Director Erin Gospodarec.

Investigation Findings:
13On 12/09/21 at 11: AM, Licensing Program Analyst (LPA) Danielle Garcia, met with Director, Erin Gospodarec to deliver the findings regarding the allegation as stated above. During the investigation, Licensing Program Analyst (LPA) Danielle Garcia was able to interview two residents (C1 and C2), five staff (S1, S2, S3, S4, S5), and record review of facility documents (Staff Contact lists, Facility Program Statement, Personnel List (LIC 500) both clients face sheets and needs and services plans). On 09/23/21, Community Care Licensing received the allegation that the facility is out of ratio. Confidential interviews revealed that staff and clients stated the facility is understaffed during transports of clients or dealing with crises. Confidential interviews revealed conflicting statements of the facility working out of ratio. ***continued on page 2*** UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Danielle Garcia 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 CCLD Regional Office, METROPOLITAN DR. # FACILITY NAME: CASA DE AMPAROFACILITY NUMBER: VISIT DATE: 12/09/2021

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


raw_content:
Narrative:
Confidential interviews also revealed that Psychiatric Emergency Response Team (PERT) was contacted to evaluate the client during the crisis, as well as the on call therapist. Confidential interviews revealed that when PERT arrived the one client became escalated. Other confidential interviews have conflicting statements whether the client was taken to the hospital for further evaluation the day of the incident. Confidential interviews revealed that staff notifies the school of the client, the day after a crisis, but did not for this incident. Review of the program statement did not reveal notifying the clients school as a required protocol. Confidential interviews could not confirm or dispute that staff did not prevent a minor from self harming while in care and that staff did not properly report an incident involving a minor. Based on interviews conducted and evidence gathered during the investigation, the allegations that staff did not prevent a minor from self harming while in care and staff did not properly report an incident involving a minor may have occurred, however is not supported, or proven by evidence. Therefore, the allegations are unsubstantiated at this time. A copy of this report, LIC 811, and appeal rights were reviewed and explained to Director Erin Gospodarec.

Investigation Findings:
On 12/09/2021 at 10: PM, Licensing Program Analyst (LPA) Danielle Garcia, met with Director, Erin Gospodarec to deliver the findings regarding the allegations as stated above. During the investigation, Licensing Program Analyst (LPA) Danielle Garcia was able to interview four residents (C1, C2, C3, C4), four staff (S1, S2, S3, S4), and record review of facility documents (Special Incident Reports, Staff Contact lists, all clients face sheets and needs and services plans). On 09/14/2021, Community Care Licensing received allegations that staff did not prevent a minor from self harming while in care and staff did not properly report an incident involving a minor. Confidential interviews revealed no clients were injured due to self harm; however, one client may have received bruises and cuts from restraints, but interviews gave conflicting statements. ***continued on page 2*** UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Danielle Garcia 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 CCLD Regional Office, METROPOLITAN DR. # FACILITY NAME: CASA DE AMPAROFACILITY NUMBER: VISIT DATE: 12/09/2021

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


raw_content:
Narrative:
by counseling them on the dangers and consequences of their actions, as well as by providing them alternatives. According to confidential interviews, staff cannot physically prevent clients from leaving, but will physically follow them as much as possible once outside of the facility, as well as file a missing person's report with local police. Confidential interviews also denied that there is a lack of supervision which results in clients assaulting other clients. According to confidential information, staff try and de-escalate clients whenever there is tension, and although staff cannot always immediately physically intervene due to sometimes requiring a need for additional backup, staff will always intervene during physical confrontations between clients. While other confidential information received by Licensing Office stated that allegations had occurred, and that staff do not always do enough to intervene whenever clients attempt to AWOL, despite knowing that clients will very likely engage in underage sex and or drug use. Other confidential information received by Licensing Office also stated that staff do not always intervene whenever clients are engaged in physical altercations, nor provide adequate supervision to prevent it. Based on confidential interviews and information obtained, the allegations that staff are advised to allow minors to engage in inappropriate activities, as well as a lack of supervision resulting in minors assaulting other minors in care, may have occurred, however they are not supported or proven by evidence. Therefore, the above allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided

Investigation Findings:
13LPA Mena met with Residential Administrative Support Manager, Stephanie Donnellan to discuss the investigative findings for the above stated allegations. An investigation was conducted by LPAs Carol Anderson and Daniel Mena regarding allegations. LPAs Anderson and Mena conducted an inspection to the Short Term Residential Therapeutic Program (STRTP) on May 26, 2021 at 12:00pm and on November 22, 2021 at 12:32pm. No immediate hazards observed. LPAs interviewed four staff (S1, S2, S3 & S4), four foster children (C1, C2, C3 & C4), as well as reviewed client and facility records. Community Care Licensing received information on May 20, 2021 alleging that staff are advised to allow minors to engage in inappropriate activities, as well as a lack of supervision resulting in minors assaulting other minors in care. Information obtained did not corroborate the allegations with a preponderance of evidence. Confidential interviews denied allegations that staff do not do enough to prevent clients from AWOLing (absence without official leave) and engaging in inappropriate activities. According to confidential interviews, staff always try and prevent and dissuade clients from AWOLing UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Daniel Mena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: CASA DE AMPAROFACILITY NUMBER: VISIT DATE: 01/07/2022

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

met_with: Stephanie Donnellan


raw_content:
Narrative:
and dissuade clients from AWOLing by counseling them on the dangers and consequences of their actions, as well as by providing them alternatives. According to confidential interviews, staff cannot physically prevent clients from leaving, but will physically follow them as much as possible once outside of the facility, as well as file a missing person's report with local police. Confidential interviews also stated that whenever children return from an AWOL, they are assessed and offered medical care if they feel it is necessary or if the child requests it. According to confidential interviews, children are not immediately taken to the hospital to seek medical attention simply for coming back intoxicated. While other confidential information received by Licensing Office stated that allegations had occurred, and that staff do not always do enough to intervene whenever clients attempt to AWOL, despite knowing that clients will engage in dangerous behaviors. Confidential information received by Licensing Office also stated that Child # 1 should have been taken to seek medical care by staff after returning to facility intoxicated, due to their young age. Based on confidential interviews and information obtained, the allegations that staff did not prevent children from AWOLing (absence without official leave), as well as did not seek medical attention for children, more specifically that staff did not take C1 to the hospital after having consumed alcohol while on AWOL, may have occurred, however is not supported or proven by evidence. Therefore, the above allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided

Investigation Findings:
13LPA Mena met with Residential Administrative Support Manager, Stephanie Donnellan to discuss the investigative findings for the above stated allegations. An investigation was conducted by LPAs Carol Anderson and Daniel Mena regarding allegations. LPAs Anderson and Mena conducted an inspection to the Short Term Residential Therapeutic Program (STRTP) on June 07, 2021 at 12:12pm and on November 22, 2021 at 12:32pm. No immediate hazards observed. LPAs interviewed four staff (S1, S2, S3 & S4), five foster children (C1, C2, C3, C4 & C5), as well as reviewed client and facility records. Community Care Licensing received information on May 27, 2021 alleging that staff did not prevent children from AWOLing (absence without official leave), as well as did not seek medical attention for children, more specifically that staff did not take C1 to the hospital after having consumed alcohol while on AWOL. Information obtained did not corroborate the allegations with a preponderance of evidence. Confidential interviews denied allegations that staff do not take enough action to prevent clients from AWOLing. According to confidential interviews, staff always try and prevent UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Daniel Mena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: CASA DE AMPAROFACILITY NUMBER: VISIT DATE: 02/03/2022

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


raw_content:
Narrative:
immediately intervene in order to dissuade clients from engaging in behavior and to convince them relinquish the contraband voluntarily. Confidential interviews also stated that staff cannot always immediately intervene in order to physically remove the alcohol from the client, in fear of getting into a power struggle or escalating the situation while the client is in the possession of a glass bottle(s). Confidential interviews stated that clients are always under the supervision of the staff and that staff will confiscate the alcohol as soon as possible, this depending on each situation, number clients involved, and staffing. While other confidential information received by Licensing Office stated that allegations had occurred, and that staff allowed Child #1 (C1) to consume alcohol, despite knowing that C1 was in the possession of it after returning from an AWOL. LPA received inconsistent information regarding the allegation. Based on confidential interviews and information obtained, the allegations that allowed minors to consume alcohol, may have occurred, however is not supported or proven by evidence. Therefore, the above allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided

Investigation Findings:
13LPA Mena met with Residential Administrative Support Manager, Stephanie Donnellan to discuss the investigative findings for the above stated allegation. An investigation was conducted by LPAs Carol Anderson and Daniel Mena regarding allegation. LPAs Anderson and Mena conducted an inspection to the Short Term Residential Therapeutic Program (STRTP) on June 14, 2021 at 10:37am and on November 22, 2021. No immediate hazards observed. LPAs interviewed four staff (S1, S2, S3 & S4), five foster children (C1, C2, C3, C4 & C5), as well as reviewed client and facility records. Community Care Licensing received information on June 07, 2021 alleging that staff allowed minors to consume alcohol. Information obtained did not corroborate the allegations with a preponderance of evidence. Confidential interviews denied allegations that staff allow clients to consume alcohol. According to confidential interviews, staff do as much as possible in order to prevent clients from bringing in alcohol to the facility after an AWOL (absence without official leave). According to confidential interviews, whenever a client is consuming alcohol at the facility and staff become aware, staff will UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Daniel Mena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: CASA DE AMPAROFACILITY NUMBER: VISIT DATE: 02/03/2022

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

met_with: Stephannie Donnellan


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Based on confidential interviews and LPA observation the preponderance of evidence standard has been met regarding the allegation that the exterior gates at the facility are locked and clients are not allowed to exit the ground. This poses a potential Health, Safety, or Personal Rights risk to the children in care; therefore, the above allegation is substantiated. The facility will be cited for violating California STRTP ILS (version 4) section 84072(c)(14) Personal Rights. An exit interview was conducted, and a copy of this report and appeal rights were left with the agency representative.

Investigation Findings:
13On March 18, 2022, at 10: AM, Licensing Program Analyst (LPA) Carol Anderson made an unannounced inspection of the facility to deliver findings for the above allegation. LPA met with Residential Administrative Support Manage Stephanie Donnellan. During the complaint investigation, LPA interviewed two of two staff. LPA observed the facility gates on the premises as locked. The Department received a complaint on November 2, 2021, alleging that exterior gates on facility premises are locked not allowing minors access. Confidential interviews revealed that the exterior gates on the facility have been locked since initial licensed on 4/27/2012. On November 9, 2021, during a complaint investigation, LPA observed the facility's exterior gates as locked, preventing clients from exiting the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Carol Anderson 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 CCLD Regional Office, METROPOLITAN DR. # FACILITY NAME: CASA DE AMPAROFACILITY NUMBER: VISIT DATE: 03/18/2022

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

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
had AWOL'ed. It was reported that on 02/06/2023, staff checked C1's bedroom and could not locate them. Confidential interviews reported that C1 was observed in their bedroom on 02/05/2023 at 9:00 pm and it was discovered that C1 was not in their bed or bedroom at 2:30 pm on 02/06/2023. Confidential interviews reported that C1 stuffed their bed and the last time C1 was observed on the Cottage Video footage was on 02/05/2023 at 8:17 pm, walking to their bedroom. Based on confidential interviews and a review of documents the allegations that staff do not adequately supervise juveniles resulting in juveniles' AWOL and staff did not realize in a timely manner that a youth had AWOL'ed are substantiated. The preponderance of evidence standard has been met. The facility is cited for violation of the California Code of Regulations, Title Division Six, regulation 84065.2(b)(1) Personnel Duties. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Stephanie Donnellan. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights will be emailed to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On 12/06/2023, at 11:45 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility and met with Stephanie Donnellan, Residential Administrative Support Manager to discuss the investigative finding for the allegations noted above. LPA Carol Anderson conducted an inspection of the facility on 02/12/2023 at 10:07 am and no deficiencies were observed. LPA Anderson interviewed one staff (S10) and LPA Linley interviewed one client (C2), LPA attempted to interview another client (C1), however, was unable to contact them despite multiple attempts, and LPA interviewed nine staff (S1-9). LPA reviewed the following documents: Cottage Roster, Staff Roster, Special Incident Report, Overnight Shift Room Check Log, Cottage Video Recording 02/05-02/06/2023, and San Diego County Sheriff's Department Missing Person Report. On 02/07/2023, Community Care Licensing (CCL) received allegations that staff do not adequately supervise juveniles resulting in juveniles' AWOL and staff did not realize in a timely manner that a youth SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 CCLD Regional Office, FACILITY NAME: CASA DE AMPAROFACILITY NUMBER: VISIT DATE: 12/06/2023

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


raw_content:
Narrative:
a preponderance of evidence. Based on confidential interviews and records reviewed that staff engaged in inappropriate behavior with C1 while in care, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was reviewed with Stephanie Donnellan. Due to printer malfunction, a copy of this report, LIC 811, and appeal rights will be emailed to the Administrator. A copy of this report will be placed in the facility file.

Investigation Findings:
13On 12/11/2023, at 11:15 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced at the facility and met with Stephanie Donnellan, Residential Administrative Support Manager to discuss the investigative finding for the allegation noted above. LPA Carol Anderson conducted an inspection of the facility on 04/25/2023 at 11:32 am and no deficiencies were observed. LPA Linley attempted to interview two clients (C1-2), however, was unable to contact them, despite multiple attempts, and interviewed seven staff (S1-7). LPA reviewed the following documents during the investigation: Staff Roster, C1's Needs and Services Plan, and Special Incident Report. On 04/19/2023, Community Care Licensing (CCL) received an allegation that staff engaged in inappropriate behavior with C1 while in care. Confidential interviews revealed conflicting statements. There were no witnesses to the allegation. Therefore, confidential interviews did not corroborate the allegation with UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 CCLD Regional Office, FACILITY NAME: CASA DE AMPAROFACILITY NUMBER: VISIT DATE: 12/11/2023

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


raw_content:
Narrative:
corroborate the allegation with a preponderance of evidence. Based on confidential interviews and records reviewed, the allegation that staff did not prevent a minor from self harm while in care, which may have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted with Stephanie Donnellan and appeal rights were reviewed. Due to printer malfunction, a copy of this report and the LIC 811 will be emailed to the Facility Administrator. A signed copy of this report will be kept in the Facility file.

Investigation Findings:
13On 12/20/2023 at 1:50 pm, Licensing Program Analyst (LPA) Charmaine Linley conducted an unannounced complaint inspection at the above facility. LPA Linley met with Residential Administrative Support Manager, Stephanie Donnellan. The purpose of the inspection was to deliver the findings of the complaint investigation. LPA Linley conducted an inspection of the facility on 03/15/2023 at 12:46 pm and no deficiencies were found. LPA interviewed three clients (C1-3) and LPA interviewed six staff (S1-6) and was unable to interview three staff (S7-9) despite multiple attempts to contact them. During the investigation, the following documents were reviewed: Cottage Roster and Special Incident Reports. On 03/15/2023, Community Care Licensing (CCL) received an allegation that staff did not prevent a minor from self harm while in care. Confidential interviews reported conflicting information as to what preventative measures staff took to prevent C1 from self-inflicting cuts in their arm. Thus, confidential interviews did not UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Charmaine Linley 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 CCLD Regional Office, FACILITY NAME: CASA DE AMPAROFACILITY NUMBER: VISIT DATE: 12/20/2023

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


raw_content:
Narrative:
It was reported that on March 13, 2024, C1 expressed concerns for their mental health to facility staff who did nothing to address C1's needs and sent C1 to school. During the investigation, a confidential interview confirmed that on March 13, 2024, C1 requested to speak to nursing due to waking up feeling mentally drained. Confidential interviews revealed C1 was attempting to be placed on sick policy which the facility utilizes for clients not to attend school when experiencing certain illnesses. Confidential interviews revealed C1 had trouble with attending school due to runaway incidents and often requesting to be placed on sick policy. A confidential interview and review of facility records revealed C1 requested S3 place them on sick policy due to feeling tired from running away the night prior, however, a conflicting confidential interview revealed C1 was not attempting to get away with not going to school. A confidential interview detailed C1 became upset because S3 would not place them on sick policy and made a comment about wanting to harm themself. A confidential interview revealed C1 was told they would need to go to school, however, a conflicting confidential interview revealed S3 reached out to facility staff to express concerns and recommended C1 speak to a clinician, which C1 declined to do. A review of facility records revealed C1 returned to their room and expressed their frustration regarding the situation with S2 and expressed feeling like they were dealing with a lot. A review of records revealed S2 gave C1 the option to speak to a clinician which was declined by C1. A review of facility records revealed that after having some time alone, C1 reported feeling okay and left going to school in a positive head space, however, a conflicting confidential interview revealed C1 was not given the option and was rather sent to school by staff in the condition they were in. Based on conflicting interviews and records reviewed, the allegation that staff did not address the mental health needs of minor in care is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation occurred. An exit interview was conducted with Stephanie Donnellan, Residential Administrative Support Manager . A copy of this report and appeal rights were provided and reviewed with Stephanie Donnellan, whose signature on this report confirms receipt of these documents.

Investigation Findings:
13On March 6, 2025, at 11: AM/PM, Licensing Program Analyst, Abby Saeteurn made an unannounced visit to Casa De Amparo and met with Stephanie Donnellan, Residential Administrative Support Manager, to deliver findings for the above stated allegation. LPA Carol Anderson initiated a complaint inspection at the facility on March 21, 2024, at 10: AM, and no immediate deficiencies were observed. During the investigation, LPA Anderson interviewed client (C1) and attempted to interview witness (W1). Additionally, LPA Saeteurn interviewed staff (S2-S6), reviewed pertinent facility records, and attempted to complete interviews with clients (C2-C3) and authorized representatives (AR1-AR3). On March 15, 2024, Community Care Licensing (CCL) received a complaint alleging staff did not address the mental health needs of a minor in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Abby Saeteurn LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: CASA DE AMPAROFACILITY NUMBER: VISIT DATE: 03/06/2025

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


raw_content:
Narrative:
A confidential interview described S1 as a staff member who was strict and would never give clients a vape pen. Confidential interviews and records reviewed did not corroborate the allegation that S1 provided C1 or other clients in care with a vape pen or contraband. Based on interviews the allegation staff gave child a vape pen is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation occurred. An exit interview was conducted with Stephanie Donnellan. A copy of this report and appeal rights were provided and reviewed with Stephanie Donnellan, Residential Administrative Support Manage whose signature on this report confirms receipt of these documents.

Investigation Findings:
13On March 24, 2025 at 3: PM, Licensing Program Analyst (LPA) Abby Saeteurn, made an unannounced visit to Casa De Amparo and met with Stephanie Donnellan, Residential Administrative Support Manager to deliver findings to the above stated allegation. LPA Carol Anderson initiated a complaint inspection at the facility on April 25, 2024, at 10: AM and no deficiencies were observed. During the investigation, LPA Anderson interviewed one client (C2). LPA Saeteurn interviewed Staff (S1 and S2), attempted to interview Client (C1) and Authorized Representatives (AR1-AR2), and reviewed pertinent facility records. On April 17, 2024, Community Care Licensing (CCL), received a complaint alleging S1 provided a client at the facility with a vape pen. During the investigation, confidential interviews revealed S1 was no longer employed at the facility due to the reported allegation; however, the investigation did not yield evidence to confirm the reason S1 was no longer employed at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Abby Saeteurn LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: CASA DE AMPAROFACILITY NUMBER: VISIT DATE: 03/24/2025

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


raw_content:
Narrative:
In regard to the allegation, It was specified that during an outing C1 inappropriately touched the private parts of C2 and C3. It was further stated that C1 also hugged and kissed C2 and C3 on the lips. During the investigation, a confidential interview stated not receiving reports of inappropriate touching or sexual interactions between clients in care. Another confidential interview stated that inappropriate behavior was not reported or witnessed by C1. One confidential interview stated C1 was vocal about dating C3. The same interview reported that C1, C2, and C3 all exhibited inappropriate behavior in front of staff and staff encouraged youth to refrain from doing so. County social workers stated not having concerns on the care and supervision from STRTP staff. Other confidential interviews did not have information regarding the allegation. Based on confidential interviews, the allegation that lack of supervision resulted in inappropriate behaviors between youth in care may have occurred, however, there was not a preponderance of evidence to support or deny the alleged violation. Therefore, this allegation is unsubstantiated at this time. An exit interview was conducted and a copy of this report, LIC 811, and Appeal Rights were provided to Stephanie Donnellan.

Investigation Findings:
13On April 9 2025, at 10:40AM, Licensing Program Analyst (LPA) Adaleyci Caballero met with Casa De Amparo Short Term Residential Therapeutic Program (STRTP) Residential Administrative Support Manager Stephanie Donnellan to discuss the investigative finding for the above stated allegation involving clients in care listed on the Confidential Names List (LIC811) dated 04/09/25. Community Care Licensing received information on June 11, 2024, alleging that lack of supervision resulted in inappropriate behaviors between youth. LPA Carol Anderson began the investigation at the facility on June 13, 2024, at 12:30PM and interviewed client #1(C1). During the investigation, LPA Caballero interviewed four staff, client #7(C7), and three County Social Workers. Client #2, #3, #4, #5, and #6 declined an interview. LPA reviewed pertinent documents from clients' files. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Adaleyci Caballero LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: CASA DE AMPAROFACILITY NUMBER: VISIT DATE: 04/09/2025

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

met_with: Support Manager-Stephanie Donnellan


raw_content:
Narrative:
In regard to allegation, it was reported that that on two occasions C1 and C2 went to the hospital for intoxication. It was specifically alleged that C1 and C2 drank alcohol, returned to the facility, left again, and returned on early hours and were passed out and taken to the hospital. A confidential interview stated staff do room checks every thirty minutes to ensure the safety of the clients. The same interview reported that clients do what they want, and staff cannot control the clients' behaviors when they're mind is set to leave the premises. Another confidential interview stated that staff could only do so much and if the clients at the STRTP plan to get drunk out of the facility, it does not involve staff supervision. A confidential interview stated that building rapport with C1 was easy due to relatable things, but it was difficult to keep C1 at the STRTP due to C1's defiance. Probation officer stated that C1 remained defiant and C1's runaway behaviors remained consistent. Other information stated the allegation occurred. Based on confidential interviews, the allegation that staff do not provide adequate supervision to minors in care may have occurred, however, there was not a preponderance of evidence to support or deny the alleged violation. Therefore, this allegation is unsubstantiated at this time. An exit interview was conducted and a copy of this report, LIC 811, and Appeal Rights were provided to Stephanie Donnellan.

Investigation Findings:
13On April 9, 2025, at 11:20AM, Licensing Program Analyst (LPA) Adaleyci Caballero met with Casa De Amparo Short Term Residential Therapeutic Program (STRTP) Residential Administrative Support Manager Stephanie Donnellan to discuss the investigative finding for the above stated allegation involving clients in care. Community Care Licensing received information on June 26, 2024, alleging that staff do not provide adequate supervision to minors in care. LPA Carol Anderson began the investigation at the facility on July 1, 2024, at 11:20AM and there was no safety concerns observed. During the investigation, LPA Caballero interviewed four staff, client #7(C7), and Probation Officer. Client #1(C1) was not interviewed due to C1 in the juvenile hall and Client #2's whereabouts are unknown due to C2's runaway status. Client #3, #4, #5, and #6 declined an interview. LPA reviewed pertinent documents from clients' files. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Adaleyci Caballero LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: CASA DE AMPAROFACILITY NUMBER: VISIT DATE: 04/09/2025

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


raw_content:
Narrative:
In regard to the above allegation, It was alleged that minor was hospitalized for swallowing a battery. It was specifically alleged that minor had been hospitalized several times for swallowing objects. A confidential interview stated that C1 was given 1:1 supervision, but C1 still found ways to find a random object to swallow. Another confidential interview reported that there was always an activity for C1 to be involved; however, C1 was so sneaky and would find objects like a pencil to swallow. The same interview revealed that all objects had to be removed from C1's bedroom, except for furniture and curtains to avoid self-harm. One confidential interview stated that due to C1's frequent swallowing of objects daily room searches were conducted to verify C1 didn't have anything C1 could swallow. Other confidential interviews did not have information regarding the allegation. Records review indicates that a CFT meeting was conducted to address placement preservation, safety concerns, and to brainstorm various interventions due to C1 self-harm behaviors on 07/11/24. Other information stated the violation occurred. Based on confidential interviews, the allegation that lack of supervision resulted in Client #1's hospitalization may have occurred, however, there was not a preponderance of evidence to support or deny the alleged violation. Therefore, this allegation is unsubstantiated at this time. An exit interview was conducted and a copy of this report, LIC 811, and Appeal Rights were provided to Stephanie Donnellan.

Investigation Findings:
13On April 9, 2025, at 11:37AM, Licensing Program Analyst (LPA) Adaleyci Caballero met with Casa De Amparo Short Term Residential Therapeutic Program (STRTP) Residential Administrative Support Manager Stephanie Donnellan to discuss the investigative finding for the above stated allegation involving client in care. Community Care Licensing received information on July 10, 2024, alleging that lack of supervision resulted in minor's hospitalization. LPA Carol Anderson began the investigation at the facility on July 18, 2024, at 11:00AM and no immediate safety concerns were observed. During the investigation, LPA Caballero interviewed four staff and client #6(C6). County Social Worker was not interviewed due to unsuccessful attempts. Client #1(C1) was not interviewed due to unsuccessful attempts to C1's placement. Client #2, #3, #4, and #5 declined an interview. LPA reviewed pertinent documents from client's file. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Adaleyci Caballero LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: CASA DE AMPAROFACILITY NUMBER: VISIT DATE: 04/09/2025

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


raw_content:
Narrative:
It was specifically reported to CCL that C1 and C2 engaged in inappropriate telephone interactions with an unknown adult, allegedly due to a lack of staff supervision in care. Confidential interviews reported that C1 misused the phone in care, allegedly resulting in C1 leaving the facility without permission and other inappropriate conduct involving C2. Other Confidential interviews reported that a safety plan was implemented to prevent C1 from misusing a cellphone while in care. Confidential interviews provided inconsistent information that would support or deny that a violation of supervision by staff resulted in the allegation. Based on confidential interviews, the allegation that a lack of supervision resulting in minors (C1 and C2) engaging in inappropriate behavior is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this report, along with the appeal rights, was provided to Stephanie Donnellan, Residential Administrative Support Manager.

Investigation Findings:
13On May 13, 2026, at 10: AM, Licensing Program Analyst (LPA) Cynthia Urena met with the Casa De Amparo Short Term Residential Therapeutic Program (STRTP) Stephanie Donnellan, Residential Administrative Support Manager to deliver the investigative findings regarding the above-stated allegation. On March 3, 2026, at 9: AM, Licensing Program Analyst (LPA) Cynthia Urena initiated the investigation at the STRTP. LPA Urena conducted a health and safety assessment of the STRTP and observed no immediate health and safety deficiencies. LPA Urena collected pertinent documents from the STRTP staff and client files to further assist the investigation. LPA Urena attempted to conduct two client interviews with (C1 and C2), but their current whereabouts are unknown, and no additional information was obtained. Interviews were conducted with three staff members (S1, S2, and S3), two county staff members, and a client witness (C3). In addition, LPA Urena conducted a record review to further assist with the investigation. On February 26, 2026, Community Care Licensing (CCL) received a complaint alleging that a lack of supervision resulted in minors (C1 and C2) engaging in inappropriate behavior. 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: CASA DE AMPAROFACILITY NUMBER: VISIT DATE: 05/13/2026

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


facility_name: CASA ESPERANZA STRTP CHINO

raw_content:
Narrative:
Based on interviews conducted with C1-C3, facility staff are usually around monitoring them. C1-C3 had similar statements in that they were unaware of the other allegations being true or happening. Interviews conducted with staff #1 (S1) stated staff were never asked to cover up or falsify schedules. S1 further stated that the full-time social worker had recently resigned and the full- time social worker from the facilities sister location was assisting the Chino facility until a replaced social worker was hired. Interview conducted with manager and staff #1 (S1) had similar statements in that facility has adequate staff to monitor all children in care and that they did not recall seeing or being asked to falsify documents or that no full social worker worked at facility. Based on the information gathered, although the allegation may have happened or is valid, the preponderance of evidence to prove the allegation was not met, therefore the allegation is unsubstantiated. An exit interview was conducted. A copy of this report Confidential Names Form and Appeal Rights were provided to the Administrator. There were no deficiencies cited during this inspection.

Investigation Findings:
13On 10/19/ Licensing Program Analyst (LPA) Dawn Mahecha made an unannounced visit to the Homes of Hope Foster Family Agency (FFA) corporate office to the Casa Esperanza Chino Short Term Therapeutic Residential Program (STRTP) for the purpose concluding the above complaint investigation. LPA met with Administrator Rod Recendez to conclude the above identified allegations. Investigation consisted of the following: On 5/3/ LPA interviewed Facility manager, therapist, two (2) childcare workers and three (3) children (see confidential names list LIC811, dated May 3, 2021). LPA toured the facility with childcare worker and facility manager. LPA observed the following this is a single story, single family residence with three (3) bedrooms, two (2) bathrooms, office space, kitchen, front yard, backyard and attached garage. On 9/24/ LPA reviewed documents received and information provided from interviews. LPA interviewed County Social Worker (CSW) and LPA reviewed information provided. Investigation revealed the following: It was alleged that staff are asked to cover up problems, children are not adequately supervised, staff schedules are falsified, facility has no full time social worker on duty and staff are not being provided training. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Yan Yeung LICENSING EVALUATOR NAME: Dawn Mahecha 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: CASA ESPERANZA STRTP CHINOFACILITY NUMBER: VISIT DATE: 10/19/2021

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

met_with: Rod Recendez, Administrator


raw_content:
Narrative:
On 11/08/2022, the Department received a complaint alleging allegations of the facility not having a therapist, including staff-to-client ratio not being followed. The Administrator denied the allegations. The Administrator stated that the facility has always had a therapist and Head of Service without any interruption in service. Furthermore, it was disclosed by the Administrator that staff is following their work schedules to the best of her knowledge she is not aware of any call-outs. The Administrator stated that whenever a client is present at the facility, there is always at least two or more staff present, one being a House Manager (HM). In confidential interviews, one client denied the allegations and stated that there is normally two or more staff working most of the time. The client disclosed that he has met with the therapist both in person and by having communicated by telephone. Interviews obtained by staff were not consistent and therefore could not corroborate the allegations. One professional collateral contact reportedly has observed on at least two occasions one staff while at the facility but was unable to provide any exact dates. It should be noted at the time of the investigation when first started on 11/14/2022, LPA Vargas obtained a copy of the Personnel Report (LIC500) dated 11/10/2022 and listed two (2) House Managers/Facility Managers. LPA obtained an updated LIC500 form dated February 2023 and shows the facility having seven (7) Facility Managers. Based on records reviewed and interviews obtained, the above allegations is determined unsubstantiated at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged abuse occurred. The resolution to this complaint was discussed with the agency representative and copies of all licensing reports were provided at the conclusion of the inspection. An exit interview was conducted and the Appeal rights given were explained. No deficiencies were cited at this time.

Investigation Findings:
13On 03/03/2023 at 10: AM, Licensing Program Analyst (LPA) Joseph Vargas conducted a follow-up inspection for the purpose of providing findings for the above complaint. LPA met with staff Ms. Gomez. During the course of the investigation, LPA conducted in-person visits, and telephone interviews with seven staff workers on 11/14/2022, one client on 11/30/2022, and client's county social worker (CSW) on 02/22/2023 (reference confidential names list LIC811 dated 02/28/2023. During the inspection LPA requested for review and obtained copy of the staff and client facility roster reports, special incident reports, clients' Needs and Service Plan, and Personnel Report (LIC500 form) dated 11/10/2022 and 02/2023. Currently, there is no county referral report that is associated with this complaint at this time. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Joseph Vargas 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 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: CASA ESPERANZA STRTP CHINOFACILITY NUMBER: VISIT DATE: 03/03/2023

met_with: Glenda Gomez, Facility Manager


summary: Complaint Investigation - Unsubstantiated - 1 deficiency

raw_content:
Narrative:
Continue from page 1. . . . Information obtained from staff and client revealed that a client locked the bathroom door and the client sustained a cut on his leg with a razor from a pencil sharpener that the client had taken apart. The staff that worked on the day of the incident was not able to open the door to the bathroom because the staff was not able to find the key to the bathroom on the facility keys ring. Other information indicated that there was no bathroom key in the key ring while other information indicated that the key to the bathroom was not in the keys ring but was in the staff cabinet. Additional information indicated that the client gave a note to one of the staff where it said that the client was going to hurt/cut himself and then went to the bathroom and locked the door. Based on the staff statements and confidential interviews the allegation is found to be substantiated. A substantiated finding means that the preponderance of evidence standard has been met and the allegation is found to be true. Exit interview completed. The following deficiencies cited and a copy of this report and appeal rights were left with facility representative mention above. Continue from page 1 . . . The staff denied the allegations and stated that the sharps objects are locked away in the facility cabinet. Information indicated that a client sustained a cut from a pencil sharpener razor that it was obtained from school and it was taken apart to get the razor from it and other information indicated that there is pencil sharpeners in the facility. The confidential interview revealed that the client got the pencil sharpener from the school and has no access to razor in the facility but that the facility staff has given her shaving razors that are not able to cut. The County Social Worker stated that she only knew the information that was reported from the facility and that the client did not want to talk about the incident with her. Based on the interview and records reviewed the allegation is found to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the allegation. Appeals rights were provided and discussed with the facility representative mention above. There were no deficiencies cited.

Investigation Findings:
13On March 17, 2023, Licensing Program Analyst (LPA) Heriberto Perez conducted a follow-up complaint inspection to the above facility and met with Neetu Chhokar, Facility Manager. The purpose of the visit was to deliver the finding for the above complaint allegation. During the course of investigating the allegation, LPA interviewed with one clients and one staff on November 22, 2022, LPA interviewed three staff and County Social Worker (CSW) via telephone on March 08, 2023, LPA interviewed two staff via telephone on March 09, 2023 and LPA interviewed one staff via telephone on March 10, 2023 (see Confidential Names LIC 811 dated March 17, 2023). LPA also reviewed documents including but not limited to Client's Need and Service Plan, Special Incident Reports and County Investigation Report. It was alleged that facility staff member did not allow other staff access to a key to unlock a bathroom door where minor was having an emergency. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Heriberto Perez 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: CASA ESPERANZA STRTP CHINOFACILITY NUMBER: VISIT DATE: 03/17/2023

Deficiencies:
80078(a): Staff not being able to open the bathroom's lock door due to not finding the key to the bathroom. 1
2
3
4
5
6
7POC:

met_with: Neetu Chhokar, Facility Manager

title: Responsibility for Providing Care and Supervision - The licensee shall provide care and supervision as necessary to meet the client's needs.This requirement was not met as evidenced by


raw_content:
Narrative:
The four facility staff members interviewed denied the allegations indicating all staff are trained on how to administer medication, staff is trained to log the medication, follow prescription instructions and what to do when client refuses medication. The staff indicated staff does not smoke marijuana at the facility. The staff indicated C1 is given his clothing allowance and taken shopping by staff for clothes on a monthly basis. The facility staff stated C1's therapeutic needs are met, C1 has wrap around services, a therapist and a psychiatrist. The staff stated staff has not observed any bruises on C1 and C1 has not reported any bruises or injuries. The staff denied being told by superiors to lie to the C1's probation officer and to licensing. Staff indicated all incident reports are reported to licensing and C1's representatives. C1 when interviewed indicated having no issues with the facility. C1 stated C1 is given his medication by staff and there have been no issues with staff administering C1's medication. C1 has not observed any staff smoking marijuana at the facility. C1 gets C1's clothing allowance each month and C1 has not sustained a bruise at the facility. C1 enjoys living at the facility and stated C1's therapeutic needs are being met. The CSW indicated CSW has not observed any issues with untrained staff administering C1's medication. CSW has not observed staff smoking marijuana at the facility. CSW stated C1's therapeutic needs are being met and CSW has not observed any bruises on C1. CSW state the facility reports all behavior incidents to CSW. C1 has not disclosed any issues with facility. LPA reviewed C1's allowance log which indicated C1 is receiving his allowance. LPA reviewed incident reports which did not indicate any injuries to C1. Based on the interviews and records reviewed the allegations is/are found unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove the allegations. Appeals rights were provided and discussed with the facility representative mention above. There were no deficiencies cited

Investigation Findings:
13On April 3, 2023 at 12: PM Licensing Program Analyst Larry Cabral (LPA) conducted a follow-up inspection for the purpose of providing findings for the above complaint allegations. LPA Cabral met with the STRTP Administrator/CEO Sukhwinder Signh. During the course of the investigation, LPA Cabral interviewed four facility staff on 12/22/22 and one client (C1) on 3/24/23 (see Confidential Names Form LIC 811 dated April 3, 2023). LPA Cabral interviewed one county social worker (CSW) on 3/22/23. LPA reviewed incident reports, medication records, allowance records, C1's needs and services plan. On 12/16/22 the Department received a complaint alleging untrained staff is administering medication to C1, staff smokes marijuana at the facility, C1's therapeutic needs are not being met, C1 is not receiving his clothing allowance, C1 sustained a bruise while in care and staff is told to lie to C1's probation officer and licensing. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Larry Cabral 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 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: CASA ESPERANZA STRTP CHINOFACILITY NUMBER: VISIT DATE: 04/03/2023

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

met_with: Sukhwinder Signh, CEO/Administrator


raw_content:
Narrative:
On 04/04/2023, the Department received a complaint alleging allegations involving a client and staff working at the facility. The following was alleged: The facility not meeting the hygiene needs of a client, one focused staff not properly trained, and staff not allowing a client to have privacy when having to meet with Licensing Division (CCL). The Chief Executive Officer (CEO) and other staff workers interviewed denied the allegations. CEO stated that the client has never complained about foot pain due to long toenails. CEO and other staff workers stated that the client is provided with manicure and pedicure services that is paid by the facility. The CEO denied the allegation that a specific staff working was not properly trained prior to working with clients. CEO provided documents for review. CEO and staff workers denied the allegation that the one client is not allowed to be interviewed alone when speaking to Licensing Division (CCL). CEO has denied falsifying training documents by anyone having access to training documents. In confidential interviews, the one client identified in the report corroborated the statements provided by the CEO and staff workers and denied the allegations. The client denied having any issues or concerns with staff at the time when interviewed by LPA Vargas. One Individual known as other was identified as having direct and specific information about the allegations reported and could not be contacted, therefore no statement was obtained. Based on records reviewed, which included training documents, training certificates, and interviews obtained, the above allegations is determined unsubstantiated at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged abuse occurred. The resolution to this complaint was discussed with the agency representative and copies of all licensing reports were provided at the conclusion of the inspection. An exit interview was conducted and the Appeal rights given were explained. No deficiencies were cited at this time.

Investigation Findings:
13On 06/20/2023 at 10: AM, Licensing Program Analyst (LPA) Joseph Vargas conducted a follow-up inspection for the purpose of providing findings for the above complaint. LPA met with staff Ms. Singh. During the course of the investigation, LPA conducted in-person visits, and telephone interviews with one staff (CEO) on 4/06/23, two staffs and one client on 4/07/2023, two staffs on 6/08/2023, one staff on 6/09/23, one staff on 6/19/2023. One individual identified as other could not be contacted after making multiple attempts to obtain a statement. Reference confidential names list LIC811 dated 06/20/2023. During the inspection LPA requested for review and obtained copy of the staff and client facility roster reports, Personnel Report (LIC500 form), and a selected view training documents for one focused staff and others. Currently, there is no county referral report that is associated with this complaint at this time. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Joseph Vargas 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 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: CASA ESPERANZA STRTP CHINOFACILITY NUMBER: VISIT DATE: 06/20/2023

met_with: Sukhwinder Singh, Chief Executive Office (CEO)


raw_content:
Narrative:
On 12/16/22 the Department received a complaint alleging staff continued to administer medication that has been discontinued by a physician, client is not receiving medications as prescribed, the facility is not following the physician's order, staff is not following the client's diet and staff is not scheduling client's medical appointments. It was alleged staff continued to give C Aspirin after it was discontinued, staff is not making C1's medical appointments, staff is not following C1's diet. S1 when interviewed indicated C1's was mistakenly taking off Aspirin by C1's psychologist, however C1's cardiologist wants C1 to remain on Aspirin for C1's heart condition. S1 indicated staff always makes C1's medical appointments and provided C1 with C1's medication. Staff follows doctors order for C1's medication. S1 stated the facility provides C1 with a healthy diet however C1 refused to eat and will eat want C1 wants to eat. S1 stated C1's weight gain was due to C1 being in juvenile hall and eating more when C1 first came back. C1 when interviewed indicated C1 has no issues with the facility. C1 stated the facility provides C1 with healthy foods however C1 will choose to eat what C1 wants to eat. C1 stated the facility takes C1 to all medical appointments. CSW when interviewed confirmed the allegations. LPA review medical appointment forms which indicated C1's appointments, C1's NSP, ICHP, cardiologist notes which indicated C1 was mistakenly taken off Aspirin and should remain on Aspirin. LPA reviewed medical appointment forms for C1's ENT, Allergist, Hematology, Depo-Provera, Holter monitor and sleep study. LPA reviewed C1's medication logs which indicated C1's daily medications were administered. Based on the interviews and records reviewed the allegations is/are found unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove the allegations. Appeals rights were provided and discussed with the facility representative mention above. There were no deficiencies cited

Investigation Findings:
13On July 5, 2023, at 9: Licensing Program Analyst Larry Cabral (LPA) conducted a follow-up inspection for the purpose of providing findings for the above complaint allegations. LPA Cabral met with the STRTP Administrator/CEO Sukhwinder Signh. During the investigation, LPA Cabral interviewed one facility staff (S1) on 3/22/23 and one client (C1) on 3/24/23 (see Confidential Names Form LIC 811 dated July 5, 2023). LPA Cabral interviewed one county social worker (CSW) on 3/22/23. LPA reviewed incident reports, medication records, C1's needs and services plan (NSP), Individual Health Care Plan (ICHP), medical exam forms, appointment records, C1's weight logs and facility menus. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Larry Cabral 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 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: CASA ESPERANZA STRTP CHINOFACILITY NUMBER: VISIT DATE: 07/05/2023

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


summary: Facility Evaluation

raw_content:
Narrative:
On 4/27/ Licensing Program Analyst (LPA) Dawn Mahecha made an unannounced visit to the Casa Esperanza STRTP Chino location for the purpose of a Case management- incident inspection. LPA spoke with Administrator and staff regarding incident: Child arrested and sent back to facility on probation: Facility representatives stated the following: Since the time of the incident identified above the staff involved with child being arrested has been terminated and the client has had a medication adjustment. Child was placed on probation for a year and facility staff have implemented the directives provided by the court and probation department. Child has continued to have behaviors but has been getting better. Child is required to do community service and facility has been working with child on behaviors and providing life coach wrap around services. Facility has requested and has been having weekly Children and Family Therapy (CFT) meetings where most staff attend. Facility has been implementing that staff attend the CFT meeting to ensure staff are on the same page and are able to address child's behaviors. Additionally, facility has obtained court order for child authorizing staff to go through child's cellphone. LPA requested the following documents: Child's most recent needs and service plans, CFT notes, probation and court directives or orders, medication log and any additional documented provided support. Based on the information provided child was arrested and placed on probation. Facility is working with client and associated agencies in providing care to child. Exit interview completed, no deficiencies observed or cited and a copy of this report was provided to staff/ Administrator.

report_type: Facility Evaluation

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On 4/27/ Licensing Program Analyst (LPA) Dawn Mahecha made an unannounced visit to the Casa Esperanza STRTP Chino location for the purpose of a Case management- incident inspection. LPA spoke with Administrator and staff regarding incident: Staff texting while driving: Facility representatives stated the following: Staff was given notice and ultimately terminated from their position based on violating company policy and rules while transporting children. LPA obtained employee termination paperwork and requested additional supportive documentation of write ups and notices of violations. Exit interview completed no deficiencies cited or observed and a copy of this report was given to staff/ Administrator.

met_with: Suky Singh, Administrator


facility_name: CASA ESPERANZA STRTP POMONA

raw_content:
Narrative:
Continue from page 1 . . . The information obtained from the facility staff indicated that there was always food available in the facility for the clients. The staff stated that staff would go shopping for food when running low. The staff indicated that the clients had alternative things to eat if they did not like the food that was cooked by the staff. The staff indicated that there were snacks and fruits available for the clients. The staff indicated that the clients would break things in the facility and the facility would repair or replace it when it could not be repair. The staff indicated that the time to repair or replacement for broken items would depend on the items but were done in a timely matter. The confidential interviews indicated that there was always food in the facility and was available to the clients. Statements from the clients indicated that there was always food and snacks available to them and they would get it form the staff if they needed something else. The confidential interviews revealed that some of the clients would break things in the facility and that the facility would fix what the clients broke in a timely matter. There was no corroborating information obtained through interviews to confirm the allegations. LPA inspected the facility and observed a sufficient supply of perishable and non-perishable food for all children in care and LPA observed all dressers in the facility to be in good repair. Based on the information obtained though interviews the allegations are found unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the allegations occurred, therefore, the above allegations are Unsubstantiated. Appeals rights were provided and discussed with the facility representative mention above. There were no deficiencies cited. An exit interview was conducted, and a signed copy of this report was left with above staff.

Investigation Findings:
13On August 24, 2021 at 11: AM, Licensing Program Analyst (LPA) Heriberto Perez conducted a follow-up complaint inspection to the above facility and and met with Maria Castaneda, Q.A. Strtp. The purpose of the inspection was to deliver the finding for the above complaint allegations. During the course of the investigation, LPA interviewed one client and four staff via telephone on 8/20/21 and LPA interviewed County Social Worker (CSW) and two clients via telephone on 08/23/21 (see Confidential Names Form LIC 811 dated August 24 2021). It was alleged that the food supply inadequate and chest of drawers are not in good repair. Continue of page 2 . . . . UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Heriberto Perez 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: CASA ESPERANZA STRTP POMONAFACILITY NUMBER: VISIT DATE: 08/24/2021

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

met_with: Maria Castaneda, Q.A. STRTP


raw_content:
Investigation Findings:
13On 10/22/2021 at 10: AM, Licensing Program Analyst (LPA) Noubar Yerkatyan conducted a follow-up complaint inspection to the above facility and met with above staff. The purpose of the visit was to discuss and deliver findings for the above compliant allegations. While investigating the allegations, LPA Qualiema Green and LPA Yerkatyan conducted interviews with Staff, Clients, and County Social Workers (see Confidential Names LIC 811 dated October 22, 2021). Certain files were reviewed such as the facility personal roster, special incident reports, and training. Confidential interviews revealed that S1 did not adequately supervise C1 and allowed him to drive a car while C1 was impaired. It was revealed that S1 drove in the middle of the night to pick C1 up during off-duty hours. As S1 approached C1, C1 drove S1's car and got a citation from law enforcement due to being impaired. Based on interviews, it was determined that S1 failed to ensure that C1 was properly supervised. Based on the information obtained, there is a preponderance of the evidence to prove that S1 failed to meet Interim Licensing Standards. Therefore, the above allegations are substantiated. Appeal Rights were given. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Noubar Yerkatyan 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: CASA ESPERANZA STRTP POMONAFACILITY NUMBER: 197804217

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

met_with: Maria Castaneda, Quality Assurance Supervisor


raw_content:
Narrative:
On 10/4/24 the Department received a complaint alleging facility staff are not preventing client in care from having inappropriate interactions with adults. Based on the information gathered during confidential interviews, facility staff indicated the client AWOL'd from the facility all the time and staff attempted to redirect client, call law enforcement, report the AWOL to client's social worker and probation officer. Facility staff talked to client about the dangers of AWOLing and attempt to provide alternatives. The facility staff indicated client has not disclosed what client does while on AWOL. CSW and PO indicate having no concerns with the supervision being provided by the facility staff. CSW indicated the facility staff is doing all they can, however client chooses to AWOL even after staff attempted to intervene. LPA was unable to interview the client due to the client being AWOL and LPA was unable to locate client throughout the investigation. The other agency's interview with client and investigative report indicated client admitted client left the facility numerous times, sometimes at nighttime, because client got bored. Client denied that the people client hung out with were adults. Client denied being picked up and dropped off at facility by adults. The client denied engaging in commercial sexual behaviors and activities. Based on the interviews and records reviewed the allegation is/are found unsubstantiated. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the allegation. Appeals rights were provided and discussed with the facility representative mentioned above. There were no deficiencies cited.

Investigation Findings:
13On January 14, 2025, at 8: AM Licensing Program Analyst Larry Cabral (LPA) conducted a follow-up inspection for the purpose of providing findings for the above complaint allegation. LPA Cabral met with the facility youth care counselor Sireth Gill. During the investigation, LPA Cabral interviewed three facility staff (AD, S2 & S3) and attempted to interview one client (C1) on 10/9/24 (see Confidential Names Form LIC 811 dated January 14, 2025). LPA reviewed incident reports, needs and service plan (NSP), behavior plan, AWOL procedures, and case plan from the facility. LPA interview one county social worker (CSW) on 10/15/24. LPA interview one probation officer (PO) on 11/13/24. LPA reviewed the other agency's interviews and investigative narrative. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Larry Cabral 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 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: CASA ESPERANZA STRTP POMONAFACILITY NUMBER: VISIT DATE: 01/14/2025

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

met_with: Sireth Gill, Youth Care Counselor


raw_content:
Narrative:
On 3/19/25 the Department received a complaint alleging facility staff did not seek medical care for minor in a timely manner. Based on the information gathered during confidential interviews, facility staff indicated the client AWOL'd from the facility and staff attempted to redirect client, law enforcement was called. The client was adamant of being taken to Loma Linda Medical Center, but there was an active shooter situation at the hospital and the client was taken to LA County Medical Center. At medical center client was on a 5585 hold and released the next day. Client was taken to Loma Linda after client refused any medical care from LA Medical Center. CSW indicated the facility staff did everything possible for the client as far as providing medical care, but the client was adamant on going to Loma Linda. CSW had no concerns as to care and supervision. Client stated she was taken to two medical facilities and she did not want to be in either one and just wanted to go to Loma Linda. Based on the interviews and records reviewed the allegation is/are found unsubstantiated. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the allegation. Appeals rights were provided and discussed with the facility representative mentioned above. There were no deficiencies cited.

Investigation Findings:
13On August 27, 2025, at 10: AM Licensing Program Analyst Pedro Ramos (LPA) conducted a follow-up inspection for the purpose of providing findings for the above complaint allegation. LPA Ramos met with Jessica Chavez, Administrator. During the investigation, LPA interviewed four facility staff, clinical director, administrator and one client (C1) on 3/28/25 and 8/21/ Confidential Names Form LIC 811 dated August 27, 2025). LPA reviewed incident reports, behavior plan, AWOL procedures, and case plan from the facility. LPA interview one county social worker (CSW) on 3/24/25. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Pedro Ramos 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: CASA ESPERANZA STRTP POMONAFACILITY NUMBER: VISIT DATE: 08/27/2025

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

met_with: Jessica Chavez, Administrator


raw_content:
Narrative:
On 6/2/25 the Department received a complaint alleging facility staff did not provide adequate supervision to a minor while in care. Based on the information gathered during confidential interviews, facility staff indicated the client would AWOL from the facility and staff would attempt to redirect client. The client would refuse to take his medication and his behaviors would escalate. The client caused damage to staff vehicle and facility vehicle and the neighbors vehicles. Police was called on occasions and the client was spoken to and the police could not arrest the client due to no witnesses. Staff stated the client was removed from the STRTP due to needing a higher level of care. The clients probation officer stated he did not have any concerns with supervision at the STRTP. Based on the interviews and records reviewed the allegation is/are found unsubstantiated. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the allegation. Appeals rights were provided and discussed with the facility representative mentioned above. There were no deficiencies cited.

Investigation Findings:
13On August 27, 2025, at 9: AM Licensing Program Analyst Pedro Ramos (LPA) conducted a follow-up inspection for the purpose of providing findings for the above complaint allegation. LPA Ramos met with Jessica Chavez, Administrator. During the investigation, LPA interviewed two facility staff, clinical director and facility manager. 6/6/25 and 8/21/ Confidential Names Form LIC 811 dated August 27, 2025). LPA reviewed incident reports, behavior plan, AWOL procedures, and case plan from the facility. LPA interview one probation officer on 8/26/25. Client was not available to be interviewed. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Pedro Ramos 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: CASA ESPERANZA STRTP POMONAFACILITY NUMBER: VISIT DATE: 08/27/2025

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


raw_content:
Narrative:
On 8/15/25 the Department received a complaint alleging facility staff did not safeguard youth's personal property. Based on the information gathered during confidential interviews, facility staff indicated the client's property was at the facility office and they were going to send it to the client, but did not have an address to ship it to. Reporting party stated she had notified the STRTP on July 30,2025 and August 14 via email where to send the property and no one replied to her emails. When LPA spoke to staff on August 21 about the emails it was reported they did receive the emails, but no one had responded. Staff did state the property was ready to be shipped out on 8/25. Although the property in question was at the office, staff did not provide a timely response to reporting party to address the whereabouts of the property. Based on the interviews and records reviewed the allegation is/are found unsubstantiated. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the allegation. Appeals rights were provided and discussed with the facility representative mentioned above. There were no deficiencies cited.

Investigation Findings:
13On 8/27/25 at 10:00AM, Licensing Program Analyst (LPA) Pedro Ramos conducted a follow-up complaint inspection to the above facility and met with above staff. The purpose of the visit was to discuss and deliver findings for the above compliant allegation. While investigating the allegation, LPA Ramos conducted interviews with Staff, CEO and reporting party on 8/21/25 (see Confidential Names LIC 811 dated August 27, 2025). Files were reviewed such as the facility personal roster, special incident reports, and training. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tira Logan LICENSING EVALUATOR NAME: Pedro Ramos 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: CASA ESPERANZA STRTP POMONAFACILITY NUMBER: VISIT DATE: 08/27/2025

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