summary: Facility Evaluation

raw_content:
Narrative:
On April 25, 2023 at 9:52am, Licensing Program Analyst (LPA) Adrian Mendez arrived unannounced at the facility to conduct an Annual Continuation inspection of the Random Annual inspection that began on 04/14/2023. LPA met with Administrator Joseph Hancock, and Facility Manager Kevin Vivas. During the inspection, LPA conducted interviews with two staff and one client. All remaining residents declined to be interviewed. All the staff records are accessible electronically via a secured records portal. LPA reviewed 5 staff files. All the staff have met the training and qualification requirements per regulation requirements. Per a review of the Community Care Licensing Information System (LIS), all staff met DOJ/FBI criminal record clearances and Child Abuse Index Check requirements. Based on the facility inspection, and file review, there are no deficiencies found at this time. An exit interview was conducted, and a copy of this report was explained to Administrator Joseph Hancock. Due to printer malfunction, this report will be emailed to Administrator Joseph Hancock.


state: CA

facility_name: SOUTH COAST CHILDRENS SOCIETY-SAN RAFAEL

summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Eduardo Barragan on July 14, 2022, at 9: AM. During the inspection, LPA Barragan met with Blake Asato, House manager and inspected the facility inside and out. LPA reviewed two clients records on site at the facility at 10 am During the review of the clients records, LPA Barragan observed 2 out of 2 clients did not have current/accurate information listed on their Psychotropic Medication Administration Record (PMAR) forms. Some of the information that was refection on the PMAR did not match the medication's. For instance the "Start and End dates" were missing on C1's forms. Additionally, the "consent dates" on C2's forms did not match his JV220. Lastly, the expiration dates wasn't indicated on C1 nor C2's PMAR either. LPA reviewed 1 of staff personnel files on site at the facility at 1: PM. LPA interviewed 1 of staff on site at 2: PM. LPA interviewed 0 of children currently taking psychotropic medication at 2: PM. LPA conducted exit interview with Blake Asato, house manager or at 2: PM LPA provided the Summary Report to Blake Asato, house manager upon completion. One deficiency was observed (refer to LIC 809D) and cited from the California Code of Regulations, Title 22, and Health & Safety Codes during the inspection

report_type: Facility Evaluation

visit_type: Case Management

met_with: Blake Asato, House manager


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Based on confidential interviews, the allegations that staff yells at minor, and staff handled minor in a rough manner, may have occurred, however are not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report, along with appeal rights were explained and provided to Program Director Rich Boyer.

Investigation Findings:
13On August 20, 2021, at 10:38am, Licensing Program Analyst (LPA) Adrian Mendez conducted an unannounced inspection with the facility and met with Program Director Rich Boyer of South Coast Children's Society-Santa Cruz to discuss the investigative findings for the allegations noted above. LPA conducted a tele-inspection with the facility on March 25, 2021, at 11:27am, no deficiencies were noted. During the investigation LPA interviewed five children (C1, C2, C3, C4, C5), and two facility staff (S1, S2). On March 17, 2021, the Department received allegations that S1 yells at C1, and S1 handled C1 in a rough manner. Confidential interviews revealed conflicting statements: Staff sometimes raise their voice so C1 can hear staff because C1 yells and screams at the facility, and S1 does yell at C1. Confidential interviews also revealed conflicting statements that no clients have been observed being handled in a rough manner, and other confidential interviews reveal that C1 was hit and pushed by S1. There were no witnesses to the alleged incidents. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Adrian Mendez 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 22-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, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY-SANTA CRUZFACILITY NUMBER: VISIT DATE: 08/20/2021

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

report_type: Complaint Investigation

met_with: Rich Boyer

complaint_status: unsubstantiated


facility_name: SOUTH COAST CHILDRENS SOCIETY-SANTA CRUZ

summary: Facility Evaluation

raw_content:
Narrative:
On June 15, 2021, at 3:19PM Licensing Program Analyst (LPA) Adrian Mendez, conducted an unannounced Post Licesning/Annual inspection of the facility. The facility converted from a Group Home to STRTP (Short Term Therapeutic Program) on September 16, 2019. LPA was met at the facility by Administrator Jude Chavez, and Program Director Rich Boyer. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, the Emergency Disaster Plan was also posted. Medications are locked and centrally stored in the staff office. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. Two bedrooms contain one twin bed, and one bedroom contained two twin beds. The facility has two bathrooms. The water temperature of the kitchen sink was tested at 3:58pm and registered at 118.2 degrees which is within the appropriate range of 105 degrees to 120 degrees. Per facility staff, no firearms or weapons are allowed in the facility. Administrator Jude Chavez is present at the facility a minimum of 20 hours a week. Appropriate staff/client ratios were verified during this inspection. Cont. on 809-C The facility employs three Clinical Support Staff, six facility managers and 12 direct care staff that are used in accordance with regulatory requirements. Licensee obtained Mental Health (MH) Certification in April 2021. Program Director has stated that National Accreditation through COA is currently being processed. The Accreditation audit began on 05/26/2021. Licensing fee payments are current. LPA discussed the following with the Administrator: Core Services, Specialty Mental Health Service, Trauma Informed Care, Client Personal Rights, and Administrative Duties. Due to time constraints and employee files being housed in their corporate office, LPA will return to the facility to conduct a continuation of staff file reviews. One facility staff was interviewed during the inspection. No clients were present at the time of the inspection. No deficiencies were found. Exit interview was conducted and a copy of this report was provided to the Administrator Jude Chavez.

visit_type: Annual

met_with: Jude Chavez


summary: Facility Evaluation

raw_content:
Narrative:
On June 22, 2021, at 2:03PM Licensing Program Analyst (LPA) Adrian Mendez conducted an unannounced annual continuation inspection from June 15, 2021. LPA met with Facility Manager Mallory Mandell. During the inspection LPA reviewed five personnel files to ensure they contained all required documentation per Title Regulations. Personnel Files are maintained off-site at the Human Resources office. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. No deficiencies were noted during the time of the inspection.

met_with: Mallory Mandell


facility_name: SOUTH COAST CHILDRENS SOCIETY - DAHLIA

raw_content:
Narrative:
Confidential interviews entailed that the residents were provided other options to Cup of Noodles. Based on confidential interviews, the allegation that staff are using inappropriate forms of discipline, may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report, along with appeal rights were explained and provided to Administrator Matthew Martinez.

Investigation Findings:
13On February 2, 2022, at 11:17am, Licensing Program Analyst (LPA) Adrian Mendez arrived unannounced to the facility and met with Administrator Matthew Martinez of Southcoast-Dahlia to discuss the investigative findings for the allegation noted above. LPA conducted an inspection with the facility on November 22, 2021 at 1:10pm, no deficiencies were noted. During the investigation LPA interviewed three children (C1, C2, C3), and one facility staff (S1). During the investigation, LPA reviewed the facility's meal menu. On November 17, 2021, the Department received an allegation that staff are using inappropriate forms of discipline. It was reported that the entire facility was being punished or on "lock down" because of the behavior of two other residents and were only allowed to eat Cup of Noodles. Confidential interviews revealed that due to a lock down the residents did not get to go on a dinner outing due to two resident's behavior. Confidential interviews also revealed that staff will maintain the dinner outing for those residents on good behavior if the facility is capable of maintaining ratio. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Adrian Mendez 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 22-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, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY - DAHLIAFACILITY NUMBER: VISIT DATE: 02/02/2022

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

met_with: Matthew Martinez


raw_content:
Narrative:
had occurred. Based on interviews and information obtained, the allegation that staff handled the child in a rough manner may or may not have occurred, however, it is not supported or proven by the evidence. Therefore, the allegation is unsubstantiated at this time. A copy of this report was provided to and reviewed with Omar Gomez, Administrator, along with the appeal right and the LIC 811. A copy of this report will be placed in the Facility file. LPA reviewed the LIC 9099 via phone with Administrator, Matthew Martinez, and he gave permission via phone to LPA approving Omar Gomez to sign the LIC 9099.

Investigation Findings:
13On April 29, 2022, at 4:10pm, Licensing Program Analyst (LPA) Charmaine Linley made an unannounced complaint inspection at the facility. LPA Linley met with Omar Gomez, Interim Administrator, to discuss and deliver the investigative findings for the allegation noted above. LPA Linley conducted an unannounced inspection of the facility on April 14, 2022. No deficiencies were observed. During the investigation, LPA Linley and LPA Mendez interviewed three clients (C1, C2, C3) and three staff (S1, S2, S3) (see confidential name list, LIC 811, dated 04/29/22. LPA Linley reviewed the following documentation: C Needs and Services Plan, Quarterly Report, and Special Incident Reports. 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 22-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, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY - DAHLIAFACILITY NUMBER: VISIT DATE: 04/29/2022

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

met_with: Omar Gomez, Interim Administrator


raw_content:
Narrative:
Confidential interviews revealed that C1's injuries were sustained due to C1 fighting back during restraints. Confidential interviews revealed that S1 has been involved in restraints with C1 at the facility. Confidential interviews resulted in conflicting statements as to whether or not S1 has restrained C1 resulting in injury to C1. Based on confidential interviews and records reviewed, the allegation that S1 restrained C1 while in care resulting in injury, may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report, along with appeal rights were explained to Administrator Joseph Hancock. Due to printer malfunction, this report will be emailed to Administrator Joseph Hancock.

Investigation Findings:
13On August 23, 2022, at 10:38am, Licensing Program Analyst (LPA) Adrian Mendez arrived unannounced to the facility and met with Administrator Joseph Hancock of Southcoast-Dahlia to discuss the investigative finding for the allegation noted above. LPA conducted an inspection with the facility on June 30, 2022, at 11:41am, no deficiencies were noted. During the investigation LPA interviewed four children (C1, C2, C3, C4), and three facility staff (S1, S2, S3). During the investigation, LPA reviewed one Serious Incident Report (SIR) dated 06/18/2022, and staff Communication Log/Shift Reports dated 06/23/2022 and 06/24/2022. On July 28, 2022, the Department received an allegation that staff restrained minor while in care resulting in injury. It was reported that on 06/26/2022, C1 was taken to the hospital due to a headache. It was reported that C1 disclosed that C1's injuries, superficial scabbed over scrapes to C1's left elbow and right shoulder, were the result of being restrained at the facility by S1. Confidential interviews revealed that S1 has never been observed restraining C1 to have caused injury to C1. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Adrian Mendez 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 22-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, THE CITY DR., SUITE FACILITY NAME: SOUTH COAST CHILDRENS SOCIETY - DAHLIAFACILITY NUMBER: VISIT DATE: 08/23/2022

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

met_with: Joseph Hancock


summary: Facility Evaluation

raw_content:
Narrative:
On June 15, 2021, at 1:07PM Licensing Program Analyst (LPA) Adrian Mendez, conducted an unannounced Post Licesning/Annual inspection of the facility. The facility converted from a Group Home to STRTP (Short Term Therapeutic Program) on September 16, 2019. LPA was met at the facility by Administrator Matt Martinez, Facility Manager Qoodseya Afredi and Program Director Rich Boyer. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors were tested and observed to be in working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods to prepare the items on the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster, the Emergency Disaster Plan was also posted. Medications are locked and centrally stored in the staff office located upstairs. Medication records were reviewed and observed to be completed with dates and staff initials on dispensing records. Individual beds were observed with clean linens, pillows, comforters, and mattresses in good repair. Two bedrooms contain one twin bed, and two bedrooms contained two twin beds. The facility has three bathrooms. The water temperature in one of the client bathrooms was tested at 1:22pm and registered at 114.2 degrees which is within the appropriate range of 105 degrees to 120 degrees. Per facility staff, no firearms or weapons are allowed in the facility. Administrator Matt Martinez is present at the facility a minimum of 20 hours a week. Appropriate staff/client ratios were verified during this inspection. Cont. on 809-C The facility employs three Clinical Support Staff, five facility managers and 6 direct care staff that are used in accordance with regulatory requirements. Licensee obtained Mental Health (MH) Certification in April 2021. Program Director has stated that National Accreditation through COA is currently being processed. The Accreditation audit began on 05/26/2021. Licensing fee payments are current. LPA discussed the following with the Administrator: Core Services, Specialty Mental Health Service, Trauma Informed Care, Client Personal Rights, and Administrative Duties. Due to time constraints and employee files being housed in their corporate office, LPA will return to the facility to conduct a continuation of staff file reviews. One facility staff was interviewed during the inspection. No clients were present at the time of the inspection. No deficiencies were found. Exit interview was conducted and a copy of this report was provided to the Administrator Matt Martinez.

met_with: Matt Martinez


summary: Facility Evaluation

raw_content:
Narrative:
On June 22, 2021, at 3:44PM Licensing Program Analyst (LPA) Adrian Mendez conducted an unannounced annual continuation inspection from June 15, 2021. LPA met with Facility Manager Mallory Mandell. Employee files were not located at the facility and required employee files to be reviewed at Southcoast-Santa Cruz located at Santa Cruz Circle, CA 92626. Five personnel files were reviewed to ensure they contained all required documentation per Title Regulations. Personnel Files are maintained off-site in the Human Resource office. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. No deficiencies were noted during time of inspection.


facility_name: ST JOHN RECOVERY HOME

summary: Facility Evaluation

raw_content:
Narrative:
On August 10, 2022 at 9:30am, Licensing Program Analyst (LPA) Monica Pavia conducted an announced pre-licensing inspection of the facility. LPA met and toured the facility with Abigail Anokwuru, Administrator, Brian Phillips, Facility Manager, Giovanna Verdin, Assistant Facility Manager, and Dave Detmers, facility maintenance. This Short-Term Residential Therapeutic Program is a one story facility located in a residential area. The facility consists of 3 client bedrooms and 1 client bathroom, living and dining areas, kitchen, laundry area, gym, and detached counseling conference room. The facility is clean, safe, sanitary, and in good repair. All passageways are unobstructed and all doors open freely. There are no bodies of water on the facility premises. Fire arms are not allowed on the facility premises. At the time of visit, the following was observed: Fire extinguishers are throughout the house. Smoke detectors are throughout the house and operational. Carbon monoxide detectors are located in the hallway, outside of the client bedrooms. Each bedroom has a bed, clean linens, and adequate drawer/cabinet space. Facility has a fire clearance. First aid kit was observed. Hot water temperature measured at 105 degrees Fahrenheit. Staff records will be kept at Advent's main office in San Jose, and will be readily available for review. Client files and medications will be centrally stored and locked in the staff office. There is a taped area outside the staff office to show clients where to stand, when medication is administered. Disinfectants and other toxic materials will be locked in the hallway closet. Extra bedding and towels are kept unlocked, in the hallway closet. Main food pantry will remain unlocked in the kitchen. The secondary pantry in the kitchen is allowed to be locked. There is a space utilized for a gym, with gym equipment. All gym equipment is in working order. Knives and sharps will be kept locked in the staff office. Site location has a live in staff bedroom and bathroom that is kept locked, and meets prelicensing requirements. Head of Services (HOS) for this location is Calvin Temple. Site location already has cameras installed. Cameras are ok to leave installed, while waiting for regulations to be written. Licensee keeps video footage for a maximum of 30 days. CCL will need access to camera video footage, at all times. Licensee agrees to meet current County safety guidelines. This property is ready for licensure, once their Plan of Operation/Program Statement (POO/PS) is approved. LPA Pavia will notify licensee, once POO/PS is approved and facility is licensed. Component II: LPA Pavia discussed with the following, with Administrator: - Administrator on site required hours - facility core services and support - facility emergency intervention plan

visit_type: Prelicensing

met_with: Abigail Anokwuru


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Shikya Belfield made an unannounced inspection to the above facility on 9/13/2023 at 11: AM. The above facility had a plan for closure on 8/23/2023. When LPA Belfield arrived at that the above facility it was observed to have no clients or staff inside. the facility was observed to be no longer operating at this home / address. LPA Belfield concluded the inspection. A copy of this report will be sent to Licensee Daniel Mahan.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Shikya Belfield, Licensing Program conducted an unannounced case management inspection with the above facility on 7/20/2023 at 12: PM. Present during this inspection were four staff. Facility Manager Mark Carpenter assisted with the inspection. The purpose of this inspection is to follow up with the facility regarding the program operations. Currently there are no clients in placement. This program is licensed as a Short Term Residential Therapeutic Program (STRTP) to serve clients ages 7 to 17 and Non minor Dependents. The Interim Licensing Standards require that all referrals made to an STRTP be kept in a log and that an assessment be completed to determine program eligibility. Based on a review of the facilities program statement and confidential interviews conducted, the program is confirmed to be operating out of compliance with the licensing regulations and their program statement by not accepting STRTP eligible clients and not conducting assessments for determination. The program does not have a record of referrals received for placement's. Facility cited for violation of Interim Licensing Standards, Section 87068.1(b) Intake procedures and 87068.05(b) Admission Determination Procedures, as described on the following page LIC 809D. An exit interview was conducted a copy of this report along with appeal rights will be sent to Facility manager Mark Carpenter, administrator Abigail Anokuwru and Licensee Daniel Mahan.

met_with: Mark Carpenter


facility_name: STARSHINE-40TH STREET

summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
Regarding the allegation that facility staff treated youth differently than other youths at the facility, it was specifically alleged that C1 has different rules from other clients. During the investigation, confidential interviews denied that C1 was treated differently than other youths in the home. An additional confidential interview stated that C1 never reported being treated differently by staff. LPA attempted to interview C1, C3 and C6 on multiple occasions but LPA was not able to. LPA was unable to gather additional information. Other confidential witnesses didn't disclose any relevant information regarding the allegation. In regard to the allegation that facility staff made fun of youth, confidential interviews denied that staff made fun of C1 or any other client. LPA attempted to interview C1, C3 and C6 on multiple occasions but LPA was not able to. LPA was unable to gather additional information. Concerning the allegation that facility staff called youth names, it was specified alleged that C1 is called names. During the investigation, confidential interviews denied that staff called C1 or any other client names. LPA attempted to interview C1, C3 and C6 on multiple occasions but was not able to. LPA was unable to gather additional information. Based on confidential interviews, the allegations that facility staff treated C1 differently than other youths at the facility, facility staff made fun of C1, and facility staff called C1 names may have occurred, however, there was not a preponderance of evidence to support or deny the allegations. Therefore, the above allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with the appeal right were reviewed and provided to facility representative.

Investigation Findings:
13On June 18, 2024, Licensing Program Analyst (LPA) Rafael Enriquez arrived at Starshine Short Term Residential Therapeutic Program (STRTP) and met with Administrator Felicia Williams to deliver the finding for the allegations stated above involving the STRTP staff and clients (C1, C2, C3, C C5 and C6) as listed on the Confidential Names List (LIC 811) dated June 18, 2024. On January 10, 2024, LPA Enriquez initiated the investigation at the STRTP and obtained pertinent documents. Additionally, LPA conducted a safety inspection of the STRTP, no immediate health and safety hazards were observed. During the inspection, LPA interviewed staff 1 & 2 (S1, S2), C2, C4, C5. LPA attempted to interview C1, C3 and C6 on multiple occasions. On January 10, 2024, Community Care Licensing (CCL) received a complaint alleging that facility staff treated youth differently than other youths at the facility, facility staff made fun of youth and facility staff called youth names. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Rafael Enriquez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE N CRP RO, MAIN ST., SUITE FACILITY NAME: STARSHINE-40TH STREETFACILITY NUMBER: VISIT DATE: 06/18/2024

met_with: Administrator -Felicia Williams


summary: Facility Evaluation

raw_content:
Narrative:
On October 1, 2021, at 9: AM Licensing Program Analysts (LPAs) Shanae Pharaoh and Adelayci Caballero arrived at Starshine - 40th Street Short Term Residential Program (STRTP). LPA, was met by Administrator Felicia Williams and granted access to the facility. The purpose of the visit is to conduct an annual inspection of the facility. At 10: AM, Administrator Felicia Williams, led the physical inspection of the facility with LPA Pharaoh. The home is set up as follows: Bedroom #1- Was furnished with two twin separate beds. Sleeps C1 & C2. Bedroom #2- Was furnished with two twin separate beds. Sleeps C3 & C4. Bedroom #3- Was furnished with two twin separate beds. Sleeps C5 & C6. Bedroom #4- Is designated as the staff office and has one bathroom inside. Bedrooms are arranged so that no more than two children share a room, and there is one child per bed. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There is adequate drawer and closet space for children's belongings. A physical plant inspection was completed and included the facility's kitchen area, three refrigerators/freezers, food storage areas, client rooms, two bathroom/showers, and community gathering area and dining area. Facility grounds are clean and free of debris and observable hazards. Sports equipment/toys/books/games were observed for client's recreation time. There is adequate indoor and outdoor activity space. Facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and the menus were posted. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsperson poster. Medications are locked and centrally stored inside staff office. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client's bathrooms was measured to be an appropriate temperature. Per the Administrator, no firearms or weapons are allowed in the facility. Licensee has Mental Health Program Approval that is valid through 06/2022. Licensee has obtained National Accreditation through CARF. The Accreditation is valid through 02/2022. Licensing fee payments have been paid and there is currently a balance of $0. There were no clients present at the facility during the inspection. LPA Pharaoh discussed core services with the Administrator, based on discussion all licensing standards have been met. LPA Pharaoh discussed the board minutes based on review of meeting minutes, the facility was found to comply with all applicable regulations. LPAs reviewed 5 of 6 client files. One client file was reviewed previously. All Needs and Services plans were up to date. LPA observed all documents to be signed by required representatives and clients. LPAs also reviewed 6 personnel files to ensure they contained all required documentation per Title Regulations and Interim Licensing Standards (ILS). See Confidential Names List (LIC 811) dated 10/1/2021. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Personnel files are retained at the administration building located in the human resources office, including hard copy and online files, and will be available to the department for review upon request. LPAs reviewed the Personnel Report (LIC 500) and schedules to ensure appropriate staffing ratios. Administrator, Felicia Williams is present at the facility a minimum of 20 hours a week, as verified by staff schedule. Appropriate staff/client ratios were verified during this inspection. All staff have updated CPR and First Aid Training in the files. S4 did not have sufficient training hours. Based on review of personnel files. The facility is being cited for violation of the Interim Licensing Standards, Version 3.1, Chapter 7.5, Section 87065.1(d)1),Training Requirements. LPA Pharaoh conducted interviews with one staff. Staff person was able to provide sufficient information in relation to the facility's STRTP Program Statement, Emergency Intervention Plan, clients' Needs and Services plan, and Reporting Requirements. Based on interviews with staff, the facility appears to be meeting Core Services/Supports requirements. An exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Administrator, Felicia Williams.

met_with: Administrator - Felisha Williams


summary: Facility Evaluation

raw_content:
Narrative:
On August 16, 2023, at 8: AM, Licensing Program Analysts (LPAs) Rafael Enriquez and Adaleyci Caballero conducted an unannounced required 2-year inspection and met with Administrator Felicia Williams. LPA disclosed the purpose of the visit and was granted entry into the facility. No clients were present and four staff were present in the facility during the inspection. The facility is a three-bedroom, two-bathroom house composed of an office, living room, dining area and kitchen. One bathroom is located inside the office for staff but used by clients for hygiene and shower purposes only. The facility has an outdoor space accessible to clients in care. Administrator Felicia Williams accompanied LPAs inside and out of the facility during inspection. A physical plant inspection was completed and included the following areas: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/video games/movies were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster. Medications are locked and centrally stored in a locked closet in the staff office. Licensee had provisions for contraceptives to be held in individually locked containers by clients. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client's bathroom was measured to be 125 degrees. Facility has cameras in common areas of the facility. The facility has an exception on file to use the cameras and are meeting the terms and conditions. Administrator Felicia Williams is present at the facility a minimum of 20 hours a week, as verified by LIC Personnel Report. Appropriate staff/client ratios were verified during this inspection. The facility employs one Psychologist, three Clinical Social Workers, and three Facility Managers. Licensee has obtained a Mental Health contract with San Bernardino County. Licensee has obtained National Accreditation through Commission on Accreditation of Rehabilitation Facilities (CARF). The Accreditation is valid through February 28, 2025. Licensing fee payments have been paid and there is currently a balance of $0.00. Personnel files were reviewed to ensure they contained all required documentation per Title Regulations. Personnel files are maintained off-site at Garden Dr. San Bernardino, CA 92404 locked in the staff office. All appropriate personnel who require Caregiver Background Checks have received Criminal Record and Child Abuse Index clearances. A review of clients' records was also completed. Client and staff interviews were conducted and revealed no health and safety concerns. An exit interview was conducted with Administrator Felicia Williams. A copy of this report and Confidential Names List (LIC 811) was given to Felicia Williams

met_with: Administrator - Felicia Williams


facility_name: STARSHINE-GARDEN DRIVE

raw_content:
Narrative:
On January 26, 2023, LPA Enriquez conducted collateral interviews at the STRTP. LPA interviewed C1, C2, S1 and S2. Regarding the allegation that staff speak inappropriately to minors in care, it was specified that staff uses profanity words towards the minors. During investigation, confidential interview stated that staff was trained on staff and client relation topic which covered appropriate language used around the clients. Confidential interviews and witnesses denied ever saying inappropriate things or hearing other staff saying inappropriate things to clients. Other confidential interviews stated that client has never had a staff curse or say anything in appropriate any clients. It was added that client has never heard staff saying profanity. In regard to the allegation that staff force minors to clean the facility multiple times a day, it was specifically alleged that staff would "drag" the minors out of bed at AM to "force" them to clean four to five times throughout the day. Confidential interviews disclosed that staff wake up clients at 5: AM to do their chores, get ready for school and eat breakfast. It was added that clients only clean twice a day, in the morning and evening. Confidential interviews stated that clients get woken up at 5:00 to do chores and get ready for school. It was added that they only clean twice a day. LPA received a conflicting information. Based on confidential interviews, the allegations that staff speak inappropriately to clients in care and that staff force clients to clean the facility multiple times a day may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, these allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report was reviewed and provided to facility representative.

Investigation Findings:
13On February 09, 2023, Licensing Program Analyst (LPA) Rafael Enriquez arrived at Starshine Treatment Center, Inc. Short Term Therapeutic Program (STRTP) and met with Facility Administrator Cynthia Horne to deliver the finding for the allegations stated above involving the STRTP staff and foster children (C1 & C2) as listed on the Confidential Names List (LIC 811) dated February 9, 2023. On August 08, 2022, Community Care Licensing (CCL) received a complaint alleging that staff speak inappropriately to minors in care and staff force minors to clean the facility multiple times a day. On August 31, 2022, at 11: AM, LPA Enriquez initiated the investigation at the STRTP and obtained documents from the files and conducted a safety inspection. There were no immediate hazards observed. LPA was unable to contact the County Social Worker. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Rafael Enriquez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: STARSHINE-GARDEN DRIVEFACILITY NUMBER: VISIT DATE: 02/09/2023

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

met_with: Facility Administrator - Cynthia Horne


summary: Facility Evaluation

raw_content:
Narrative:
On September 16, 2021, Licensing Program Analysts (LPAs) Cindy Hamilton and Adaleyci Caballero met with Antoinette Borders-Frazier, Program Coordinator and Sheri Heckman, Facility Manager II. The purpose of this visit was to conduct an annual inspection of the Short Term Residential Therapeutic Program (STRTP). The facility converted from a Group Home to Short Term Therapeutic Program (STRTP) on September 14, 2017. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment is located in the backyard. Books/games were observed for client's recreation time in the dining area. There is also a laptop available for client use. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of non-perishable foods. Currently, there are no clients in placement so no perishable foods were on grounds. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster. Medications are locked and centrally stored in a locked cabinet in the locked staff office. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client's hallway bathroom was measured to be 117.1 degrees Fahrenheit, which is within the allowed range of 105-120 degrees Fahrenheit. The facility does not have a pool. Per Program Coordinator, no firearms or weapons are allowed in the facility. Licensee is in the process of being recertified for Mental Health Program Approval. Licensee has obtained National Accreditation through Commission on Accreditation of Rehabilitation Facilities (CARF). The Accreditation is valid through 02/28/2022. Licensing fee payments have been paid and there is currently a balance of $0.00. LPA Caballero discussed the following with the Facility Manager, II and Program Coordinator: Incident reporting, including incidents related to Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. LPA discussed procedures for Child and Family Team (CFT) meetings, including an overview of required Core Services and Supports. Based on this discussion the facility appears to be meeting the mission values of the facility and needs of services when clients are present.. Due to facility not having placements, no client file reviews or interviews were conducted. No deficiencies were noted in the areas during time of inspection. A copy of this report was provided to Program Coordinator Antoinette Borders-Frazier, with the Confidential Names List, LIC 811 and appeal rights..


summary: Facility Evaluation

raw_content:
Narrative:
On September 14, 2023, at 10: AM, Licensing Program Analysts (LPAs) Rafael Enriquez and Karen Beal conducted an unannounced required 2-year inspection and met with Administrator Cynthia Horne. LPAs disclosed the purpose of the visit and was granted entry into the facility. Two clients were present and five staff were present in the facility during the inspection. The facility is a two-bedroom, two-bathroom house composed of two offices, living room, dining area, garage and kitchen. Garage is used and laundry room and game room for clients. One bathroom is located inside the office for staff. The facility has an outdoor space accessible to clients in care. Administrator Cynthia Horne accompanied LPAs inside and out of the facility during inspection. A physical plant inspection was completed and included the following areas: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/video games/movies were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster. Medications are locked and centrally stored in a locked cabinet in the staff office. Licensee had provisions for contraceptives to be held in individually locked containers by clients. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client's bathroom was measured to be 125 degrees and had caution signs near all faucets. Facility has cameras in common areas of the facility. The facility has an exception on file to use the cameras and are meeting the terms and conditions. Administrator Cynthia Horne is present at the facility a minimum of 20 hours a week, as verified by LIC Personnel Report. Appropriate staff/client ratios were verified during this inspection. The facility employs one Psychologist, three Clinical Social Workers, and six Facility Managers. Licensee has obtained a Mental Health contract with San Bernardino County. Licensee has obtained National Accreditation through Commission on Accreditation of Rehabilitation Facilities (CARF). The Accreditation is valid through February 28, 2025. Licensing fee payments have been paid and there is currently a balance of $0.00. Personnel files were reviewed to ensure they contained all required documentation per Title Regulations. Personnel files are maintained on site locked in the staff office. All appropriate personnel who require Caregiver Background Checks have received Criminal Record and Child Abuse Index clearances. A review of clients' records was also completed. Client and staff interviews were conducted and revealed no health and safety concerns. An exit interview was conducted, and a copy of this report was given to Cynthia Horne.

met_with: Administrator -Cynthia Horne


facility_name: STARSHINE TREATMENT CENTER, INC.

raw_content:
Narrative:
On October 20, 2022, LPA Enriquez conducted collateral interviews at the STRTP. LPA interviewed FC1, FC2, FC3, FC4, S1, S2 and S3. On October 24, 2022, LPA conducted a collateral interview for FC5 and FC2 at San Gorgonio High school, LPA was unable to interview FC2 due to FC2 was in absence without leave (AWOL). Regarding the allegation that staff does not treat children equally, it was specifically alleged staff show favoritism among children and don't treat all children equally. Confidential interview stated that FC1 felt they were treated equally as everyone else. Additionally, confidential interview stated foster children like their relationship with staff. Confidential interviews stated staff treat all children equally. It was added that every child requires a different level of attention and if staff sees that a child needs more attention seeking due to any challenges then they provide the attention to the child needs. Confidential interviews denies treating foster children unequally. In regard to the allegation that staff speaking inappropriately about child in care, it was specifically alleged that a staff member saw FC5 without the mask and commented that FC5 "looked like a camel". Confidential interviews disclosed that they did not hear staff say FC5 looked like a camel. It was added that staff would not say anything inappropriate to foster children. Confidential interviews denied speaking inappropriately to foster children. The confidential interview reported that due to the children's ages staff sometimes need to speak very directly to them if there are any behavior issues. Based on confidential interviews, the allegations that staff does not treat children equally and that staff spoke inappropriately to FC5, may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, these allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report was reviewed and provided to facility representative.

Investigation Findings:
13On November 30, 2022, Licensing Program Analyst (LPA) Rafael Enriquez arrived at Starshine Treatment Center, Inc. Short Term Therapeutic Program (STRTP) and met with Facility Administrator Christina Garcia to discuss the finding for the allegations stated above involving the STRTP staff and foster children (FC1, FC2, FC3, FC4 and FC5) as listed on the Confidential Names List (LIC 811) dated November 30, 2022. On June 23, 2022, Community Care Licensing (CCL) received a complaint alleging staff does not treat children equally and staff spoke inappropriately about child in care On July 01, 2022, at 01: PM, LPA Enriquez and Licensing Program Manager (LPM) Traore initiated the investigation at the STRTP and obtained documents from the files and conducted a safety inspection. There were no immediate hazards observed. LPA was unable to contact the County Social Worker. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Rafael Enriquez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., Suite Riverside, CA Facility Name: Starshine Treatment Center, INC.FACILITY NUMBER: VISIT DATE: 11/30/2022

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

met_with: Facility Administrator Christina Garcia


raw_content:
Narrative:
Regarding the allegation that staff hits minor(s) in care, it was specifically alleged that S4 has physically assaulted C1 on multiple occasions. During investigation, confidential interviews stated that C1 was hit by S4. It was added that C1 was punched in the shoulder, poked, ear flicked and slapped behind the head, and that happened multiple times, however, additional confidential interviews stated that they had not seen S4 hitting C1 or any other client in care. LPA unable to gather additional information. In regard to the allegation that staff handles minor(s) in rough manner, it was specifically alleged that a staff member placed C1 in a chokehold. Confidential interviews stated that C1 was put in a chokehold by S4. Additional confidential interviews stated that they had not seen S4 putting C1 or any other client in care in a chokehold. LPA unable to gather additional information. Other witnesses didn't provide information pertaining directly to the incidents. Concerning the allegation that staff speaks inappropriately to minor(s) in care, it was specifically alleged that a staff member taunted C1 saying, now I got your ass, what are you going to do. Confidential interviews stated that S4 had not spoken to C1 inappropriately but did to other clients. Additional confidential interviews denied that S4 spoke inappropriately to clients in care. LPA was not able to interview S4. LPA unable to gather additional information. Based on confidential interviews, the allegations that S4 hits minor(s) in care, staff handles minor(s) in rough manner and staff speaks inappropriately to minor(s) in care may have occurred, however, there was not a preponderance of evidence to support or deny the allegations. Therefore, the above allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report was reviewed and provided to the facility representative.

Investigation Findings:
13On February 09, 2024, Licensing Program Analyst (LPA) Rafael Enriquez arrived at Starshine Treatment Center, Inc. Short Term Therapeutic Program (STRTP) and met with Program Coordinator- Antoinette Borders-Frazier to discuss the finding for the allegations stated above involving the STRTP staff and clients (C1, C2, C3, C C5 and C6) as listed on the Confidential Names List (LIC 811) February 09, 2024. On August 10, 2023, at 12: PM, LPA Enriquez initiated the investigation at the STRTP and obtained documents from the files and conducted a safety inspection, no immediate hazards observed. LPA interviewed C1, C2, C3, C4, C5, S1, S2 and S3. LPA was unable to contact S4 due to S4 termination with the STRTP and not having a valid contact information. On July 31, 2023, Community Care Licensing (CCL) received a complaint alleging staff hits minor(s) in care, staff handles minor(s) in rough manner and staff speaks inappropriately to minor(s) in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Rafael Enriquez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., Suite Riverside, CA Facility Name: Starshine Treatment Center, INC.FACILITY NUMBER: VISIT DATE: 02/09/2024

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


summary: Facility Evaluation

raw_content:
Narrative:
On the above date Licensing Program Analyst (LPA) Daniel Mena met with Administrator, Christina Garcia who guided analyst on an inspection to the home. The purpose of this visit is to conduct an annual inspection of the Short Term Residential Therapeutic Program (STRTP). The home was toured both inside and out with Ms. Garcia. Presently there are six foster children in placement and none were present during time of inspection (See LIC 811). The home is a one story, four bedroom and two bathroom home. The home is set up as follows: Bedroom #1- Was furnished with two twin separate beds. Sleeps C5 & C6. Bedroom #2- Was furnished with two twin separate beds. Sleeps C2 & C4. Bedroom #3- Was furnished with two twin separate beds. Sleeps C1 & C3. Bedroom #4- Is designated as the staff office and has one bathroom inside. Bedrooms are arranged so that no more than two children share a room, and there is one child per bed. No room commonly used for other purposes is used as a bedroom, and no bedroom serves as a passageway to another room. There is adequate drawer and closet space for children's belongings. Inside the facility there are operable smoke detectors located in each bedroom. There is also an operable carbon monoxide detector located in the TV room. The fireplace is properly screened. The medications are locked and stored in a locked box inside a locked medicine cabinet. Cleansers/chemicals are locked and stored in a locked cabinet inside the garage. Sharp knives are inaccessible and stored in a locked cabinet in the office. The First Aid Kit is located in the kitchen and contains all required items. There are no guns or weapons in the home. The hot water temperature was tested and noted to be 107. Proper storage of all food was noted. The Emergency Disaster Plan posted at this time. A copy of the license was readily available to LPA during time of inspection. The backyard where children will have access to play is completely fenced and free of hazards. Games and equipment is safe, clean and age appropriate for the age group of children to be cared for both inside and outside the facility. A review of five staff records and all six clients residing in facility were made. All adults in the home or providing care and supervision to children have received fingerprint and child abuse index check clearances. There were no deficiencies cited at this time. Exit interview conducted and a copy of this report was reviewed and given to Ms. Garcia with the LIC 811.

met_with: Christina Gracia


summary: Facility Evaluation

raw_content:
Narrative:
On August 30, 2023, at 10: AM, Licensing Program Analysts (LPAs) Rafael Enriquez and Adaleyci Caballero conducted an unannounced required 2-year inspection and met with Administrator Christina Garcia. LPAs disclosed the purpose of the visit and was granted entry into the facility. Four clients were present and five staff were present in the facility during the inspection. The facility is a three-bedroom, two-bathroom house composed of two offices, living room, game room, dining area and kitchen. One bathroom is located inside the office for staff. The facility has an outdoor space accessible to clients in care. Administrator Christina Garcia accompanied LPAs inside and out of the facility during inspection. A physical plant inspection was completed and included the following areas: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/video games/movies were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsman poster. Medications are locked and centrally stored in a locked cabinet in the staff office. Licensee had provisions for contraceptives to be held in individually locked containers by clients. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client's bathroom was measured to be 125 degrees and had caution signs near all faucets . Facility has cameras in common areas of the facility. The facility has an exception on file to use the cameras and are meeting the terms and conditions. Administrator Christina Garcia is present at the facility a minimum of 20 hours a week, as verified by LIC Personnel Report. Appropriate staff/client ratios were verified during this inspection. The facility employs one Psychologist, one Clinical Social Worker, and Facility Managers. Licensee has obtained a Mental Health contract with San Bernardino County. Licensee has obtained National Accreditation through Commission on Accreditation of Rehabilitation Facilities (CARF). The Accreditation is valid through February 28, 2025. Licensing fee payments have been paid and there is currently a balance of $0.00. Personnel files were reviewed to ensure they contained all required documentation per Title Regulations. Personnel files are maintained on-site in locked cabinets in the staff office. All appropriate personnel who require Caregiver Background Checks have received Criminal Record and Child Abuse Index clearances. A review of clients' records was also completed. Client and staff interviews were conducted and revealed no health and safety concerns. An exit interview was conducted, and a copy of this report was given to Christina Garcia.

met_with: Administrator- Christina Garcia


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analysts (LPAs) Sarah Lo and Joon Choi on 01/23/2024 at 09: AM. The case management inspection is conducted pursuant to Health and Safety Code Section 1538.9(a)(2). During the inspection, LPAs met with Christina Garcia, Administrator and inspected the facility inside and out. LPAs reviewed 1 children's records on site at the facility. LPAs reviewed 5 staff personnel files on site at the facility. LPAs reviewed 1 child's psychotropic medications and medication records. LPAs interviewed two staff on site to discuss the facilities policies and procedures of operation. LPAs will interview 1 child that is currently prescribed psychotropic medication after the facility visit. No deficiencies are being cited at this time. LPAs provided a copy of this licensing reporting and conducted an exit interview with Christina Garcia.

met_with: Christina Garcia, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On August 7, 2024, at 8: AM, Licensing Program Analyst (LPA), Cynthia Urena met with Starshine Treatment Center, Inc. Short Term Residential Therapeutic Program (STRTP) Administrator, Cynthia Horne regarding a case management inspection at the facility. The purpose of the inspection is to obtain additional information regarding information received by LPA on 07/29/24. LPA Urena conducted interviews with five staff members (S1, S2, S3, S4, S5) and two clients (C1, C2). Additionally, LPA requested copies of pertinent documentation to further assist with the case management. A copy of this report was provided to Starshine Treatment Center, Inc. Short Term Residential Therapeutic Program (STRTP) Administrator, Cynthia Horne.

met_with: Administrator, Cynthia Horne


summary: Facility Evaluation

raw_content:
Narrative:
On December, 31 2024 , at 9: AM, Licensing Program Analyst (LPA), Jacob Ortega and Licensing Program Manager (LPM) Nicole Strickland met with Facility Manager Sheri Heckman, regarding a case management inspection at the facility.The purpose of the inspection is to obtain additional information regarding information received by LPA on 12/16/24. LPA Ortega conducted two interviews. Additionally, LPA requested copies of pertinent documentation to further assist with the case management. A copy of this report was provided to Sheri Heckman, Facility Manager.

met_with: Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On January, 7 2024 , at 10: AM, Licensing Program Analyst (LPA), Jacob Ortega and Licensing Program Manager (LPM) Nicole Strickland met with Facility Administrator Christina Garcia, regarding a case management incident initiated on January 31, 2024 .While at the facility LPA and LPM conducted two interviews and collected additional pertinent documents. No deficiencies cited at this time. A copy of this report was provided to Christina Garcia, Facility Administrator.

met_with: Christina Garcia


summary: Facility Evaluation

raw_content:
Narrative:
On September 8, 2021, Licensing Program Analyst (LPA) Shanae Pharaoh arrived at Starshine Treatment Center, Inc. Short Term Residential Program (STRTP). LPA, was met by Assistant Executive Director, Cecilia Pace and Administrator Cynthia Horne and granted access to the facility. The purpose of the visit is to conduct an annual inspection of the facility. At 10: AM, Assistant Executive Director, Cecilia Pace and Administrator Cynthia Horne, led the physical inspection of the facility with LPA Pharaoh. A physical plant inspection was completed and included the facility's, game room, kitchen area, refrigerator/freezers, food storage areas, client rooms, bathroom/showers, and two community gathering areas. Facility grounds are clean and free of debris and observable hazards. Sports equipment/toys/books/games were observed for client's recreation time. There is adequate indoor and outdoor activity space. Facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and the menus were posted. All required forms are posted including the Grievance Procedures, Visitation Policies, Personal Rights form, and Foster Care Ombudsperson poster. Medications are locked and centrally stored inside staff office. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client's bathrooms was measured to be an appropriate temperature. Per the Assistant Executive Director , no firearms or weapons are allowed in the facility. Licensee is in the process of being recertified for Mental Health Program Approval. Licensee has obtained National Accreditation through CARF. The Accreditation is valid through 02/2022. Licensing fee payments have been paid and there is currently a balance of $0. There were no clients present at the facility during the inspection. LPA Pharaoh discussed core services with the Administrator, based on discussion all licensing standards have been met. LPA Pharaoh requested the Board of Directors meeting minutes, based on review of meeting minutes, the facility was found to comply with all applicable regulations. LPA reviewed 6 of 6 client files. All Needs and Services plans were up to date. LPA observed all documents to be signed by required representatives and clients. LPA also reviewed 5 personnel files to ensure they contained all required documentation per Title Regulations and Interim Licensing Standards (ILS). See Confidential Names List (LIC 811) dated 09/8/2021. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Personnel files are retained at the administration building located in the human resources office, including hard copy and online files, and will be available to the department for review upon request LPA reviewed the Personnel Report (LIC 500) and schedules to ensure appropriate staffing ratios. Administrator, Cynthia Horne is present at the facility a minimum of 20 hours a week, as verified by staff schedule. Appropriate staff/client ratios were verified during this inspection. 2 of 5 staff files, S2 and S5, did not have updated CPR and First Aid Training in the files. Based on review of personnel files. The facility is being cited for violation of the Title 22, Section 80065(f)(1) through (6) Personnel Requirements. LPA observed staff to have appropriate amount of training hours. LPA Pharaoh conducted interviews with 2 staff. All staff were able to provide sufficient information in relation to the facility's STRTP Program Statement, Emergency Intervention Plan, clients' Needs and Services plan, and Reporting Requirements. Based on interviews with staff, the facility appears to be meeting Core Services/Supports requirements. An exit interview was conducted and a copy of this report, LIC 809-d and appeal rights were provided to Administrator, Cynthia Horne. .

met_with: - Cecilia Pace Administrator - Cynthia Horne


facility_name: STELLA MARIS GROWTH CENTER II

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
asked to sign in, report temperature, wash or sanitize hands, or wear a mask. Information obtained from staff stated that CDC guidelines were being followed and the facility was put on quarantine status after the positive test results were received. It was also advised that authorized representatives were not advised on the onset of symptoms. It was reported that the facility did allow Client #6 to go on a visit while experiencing Covid-19 related symptoms and waiting for test results. Information obtained from confidential interviews stated that staff were enforcing quarantine status, wearing masks, and washing hands and disinfecting the facility often. LPA Harris requested and reviewed facility's log book and observed that a visitor was allowed in the home while waiting for test results. Based on interviews, there is a preponderance of evidence to prove that the facility failed to take necessary precautions to prevent the spread of Covid-19. Therefore, the above allegation is substantiated. This poses a health, safety, and/or personal rights risk to the foster children in care. The facility will be cited on California Code of Regulations (CCR) 84072(d) Personal Rights. Exit interview conducted. A copy of the report was explained and provided to the representative.

Investigation Findings:
13On October 6, 2021, at 3: PM, Licensing Program Analyst, (LPA) Jazmond Harris conducted a visit to the Short Term Residential Treatment Program (STRTP) and met with Facility Manager, Tracy Mitchell. The visit was conducted in order to provide the findings for the investigation pertaining to the listed allegation. LPA Harris initiated the investigation on August 13, 2021 at 2: PM. During the investigation, LPA Harris conducted interviews with Facility Manager, Staff Member, two out of six clients (See Confidential Names List (LIC 811) date October 6, 2021), and additional witness. Two clients refused to be interviewed and two clients were and remained on AWOL (absent without leave) status. LPA Harris was unable to obtain contact with assigned county social workers. On August 3, 2021, Community Care Licensing (CCL), received information which stated facility failed to take necessary precautions to prevent the spread of Covid-19. It was reported that after clients reported symptoms and were awaiting test results and the facility allowed a visitor to the home. It was reported that the visitor was allowed access inside the home and bathroom area. It was also advised that upon entrance the visitor was not asked to sign in, report temperature, wash or sanitize hands, or wear a mask. Information obtained from SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Jazmond D Harris LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: STELLA MARIS GROWTH CENTER IIFACILITY NUMBER: VISIT DATE: 10/06/2021

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

met_with: Facility Manager-Tracy Mitchell

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Substantiated

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Investigation Findings:
13On January 24, 2022, Licensing Program Analyst (LPA) Sarah Smith arrived at the facility and met with Stella Maris Facility Manager, LaKeicha Chaney regarding the above complaint allegation. During a Health and Safety inspection at the facility on 01/19/2022, LPA Smith observed electrical outlets in bedroom #1 that were missing covers. LPA Smith also noted that the prongs on a electrical plug appear to be burnt. During confidential interviews it was reported that when using the outlet sometimes it cause the eletricity in the home to go out or sparks can be seen. Based on LPA observations, facility is cited for Title Regulations 80087 (a) Buildings and Grounds which poses an immediate health, safety and/or personal rights risk to clients in care. A copy of this report along with appeals rights and LIC421FC were provided to Facility Manager, LaKeicha Chaney. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Sarah Smith LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: STELLA MARIS GROWTH CENTER IIFACILITY NUMBER: 336402176

met_with: LaKeicha Chaney, Facility Manager


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Narrative:
copies of each incident. Confidential interviews revealed that there was an incident where C1 was Absent Without Leave (AWOL) and it was not reported to C1's CSW. However, the CSW for C1 could not be contacted to verify that they did not receive a copy of this incident or the other incidents that CCL did receive. During the health and safety inspection LPA conducted on 11/15/2021 the facility kitchen appeared to be in proper operating condition. Confidential interviews revealed that the facility kitchen was recently remodeled. It was revealed that the kitchen was nonfunctional for approximately one month. Confidential interviews revealed that during this time the Facility Administrator would allow the clients to decide on what they wanted to eat for dinner which included dining out. In the event that the clients did not agree they would be allowed to eat different things. However, on a subsequent visit to the facility it was revealed that the facility oven does not work and one of the burners on the stove top was not function. It is unclear how long the oven has not been functional. Based on confidential interviews and record review, the allegations that staff do not follow proper reporting requirements and facility kitchen is in disrepair may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. A copy of this report and Appeals Rights were provided and explained to Facility Manager, Tracy Mitchell. their suspension, S1 was retrained on Personal Rights of the clients in care. Other confidential interviews revealed that the manner in which the staff spoke to C1 was more along the lines of how a grandmother might speak to their own granddaughter. It is not believed that S1 was trying to be mean or out of anger to C1. Confidential interviews also revealed that the placement for C1 is not going well and C1 does not always listen to directives. LPA received consistent confidential information regarding S1 speaking inappropriately to C1. Based on confidential interviews staff spoke inappropriately to minor is substantiated. The preponderance of evidence standard has been met. Facility is cited for violation of Interim Licensing Standards (ILS) Chapter 7.5 version 4 standard 87072(C)(11) Personal Rights. Exit interviewed conducted. A copy of this report and appeal rights were given and explained to Tracy Mitchell, Facility Manager.

Investigation Findings:
13On February 04, 2022 at 12:00 p.m., Licensing Program Analyst (LPA), Sarah Smith conducted an inspection with Facility Manager, Tracy Mitchell of Stella Maris Growth Center II Short Term Residential Therapeutic Program (STRTP), to discuss the investigative findings for the allegation listed above. On 11/15/2021 at 10:55 a.m., LPA conducted a safety inspection of the STRTP, and no immediate safety hazards were observed. During the investigation, LPA obtained copies of records for the facility and the clients in care (C1, C2, C3, C4, and C5). Interviews were conducted with four staff and one client (C1). The County Social Worker (CSW) for C1 is on leave and could not be interviewed. C2, C3, and C4 refused to be interviewed. C5 was on an extended leave with biological family. On November 15, 2021, Community Care Licensing (CCL) received information that staff spoke inappropriately to minor in care. During confidential interviews it was revealed that Staff 1 was suspended on October 31, 2021 without pay for speaking inappropriately to C1. Upon return SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Sarah Smith LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: STELLA MARIS GROWTH CENTER IIFACILITY NUMBER: 336402176

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

met_with: Tracy Mitchell, Facility Manager


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Narrative:
was an incident report created by the school. It is unclear where C1 got the vape pen, but it was revealed during confidential interviews that the vape pen was the property of C1's boyfriend who attends school with C1. Confidential interviews revealed that when a client is suspected of being in possession of drugs there is a safety check performed. It was also revealed that after a client returns from being Absent WithOut Leave there is also a safety check performed. During confidential interviews it was revealed that there was an incident where Law Enforcement came to the facility to search C1's belongings because they received a report that there were drugs in their possession. It was also revealed that C1 may have been in possession of ecstasy and tried to give it to another client. It is unclear where C1 is getting the drugs from. During confidential interviews it was revealed that C1 was suspended from school for the incident regarding the vape pen, however when the school called the facility to pick up C1 the school was told that there was no one available to come and get C1 at the time. The school that C1 attends is far from the facility and the staff that were present do not drive that distance. Once there was a staff member able to get C1 staff was told that it was too late to come and get C1 from school. It is unclear if the time frame that these events occurred were unreasonable. With regard to reporting incidents to the authorized representative during confidential interviews it was revealed that the authorized representative for C1 has been on leave. It could not be verified whether or not they were properly notified. Based on confidential interviews and record review, the allegations that a lack of supervision resulting in minor in possession of drugs while at facility, facility staff failed to provide transportation to minor by refusing to pick up minor from school, and facility is not reporting incidents to authorized representative may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. A copy of this report and Appeals Rights were provided and explained to Facility Manager, Tracy Mitchell.

Investigation Findings:
13On February 04, 2022 at 12:30 p.m., Licensing Program Analyst (LPA) Sarah Smith met with Stella Maris Growth Center II Short Term Residential Therapeutic Program (STRTP) Facility Manager, Tracy Mitchell to deliver the finding of the complaint investigation for the above allegations. LPA Smith conducted a safety inspection of the facility on 12/09/2021 at 9:00 a.m. and no immediate deficiencies were observed. During the course of investigating the allegations, LPA Smith conducted confidential interviews with four staff, one client, and school personnel. The County Social Worker (CSW) for C1 is on leave and could not be interviewed. LPA reviewed reports and the records for the facility and clients (C1, C2, C3, C4, and C5). On December 03, 2021, a complaint was received that a lack of supervision resulting in minor in possession of drugs while at facility, facility staff failed to provide transportation to minor by refusing to pick up minor from school, and facility is not reporting incidents to authorized representative. During confidential interviews it was revealed that C1 was caught at school in possession of a vape pen. There UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Sarah Smith LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: STELLA MARIS GROWTH CENTER IIFACILITY NUMBER: VISIT DATE: 02/04/2022

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


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Narrative:
and Child #2 (C2) having the ability to engage in inappropriate sexual interactions. Video footage obtained by the facility shows one unidentified male approaching the facility on January 31, 2022 at 12:09 am. A second male was seen running from the facility at 12:54 am, his time of arrival was unable to be determined. Confidential interviews provided conflicting statements as to the age of the males. LPA observation of the video footage is unable to confirm or dispute that the males seen approaching and leaving the facility were adults. Confidential interviews reported C1 and C2 gave the two unknown males access to the facility. Record review revealed staff heard sexual sounds coming from C1 and C2's room at about 12:38 am and attempted to gain access to the room and was told to go away. Record review further revealed that staff went back to the room after an unknown length of time and found the unknown males with C1 and C2, at which time the males ran from the facility. Record review reveals that the facility was operating with adequate staff to client ratios and were conducting safety checks regularly. Other confidential information disclosed that a lack of supervision occurred. LPA received inconsistent information regarding the allegations. Based on video footage, record review, and confidential interviews the allegations alleging lack of supervision resulted in child engaging in inappropriate sexual interaction and uncleared adult gained access into the facility, may or may not have occurred, however it is not supported or proven by the evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of the report was provided along with appeal rights to Stella Maris Growth Center II, Facility Manager (FM), Tracy Mitchell.

Investigation Findings:
13On June 8, 2022 at 9:25am Licensing Program Analyst (LPA), Nicole Strickland, met with Stella Maris Growth Center II, Facility Manager (FM), Tracy Mitchell, to deliver the finding for the above stated allegations. LPA conducted an inspection of the facility on February 14, 2022 at approximately 2:08 pm, immediate deficiencies were observed, and citations were issued. The investigation was conducted by LPA Strickland and included interviews with, four of four foster children (Child #1 [C1], Child #2 [C2], Child #3 [C3], and Child #4 [C4]), two staff members (Staff #1 [S1] and Staff #2 [S2]) and three County Social Workers (CSW#1, CSW#2, CSW#4). One confidential witness did not respond to LPA's request for an interview and therefore was not interviewed. In addition, video footage, county records and facility records were reviewed. On February 7, 2022, Community Care Licensing (CCL) received two allegations alleging lack of supervision resulted in child engaging in inappropriate sexual interaction and uncleared adult gained access into the facility. Specifically it was reported two unknown males gained access to the facility resulting in Child #1 (C1) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Nicole Strickland LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: STELLA MARIS GROWTH CENTER IIFACILITY NUMBER: VISIT DATE: 06/08/2022

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


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Narrative:
On April 28, 2022, at 12:25PM Licensing Program Analyst (LPA) S. Smith initiated the investigation at Stella Maris Growth Center Short Term Residential Therapeutic Program (STRTP). At 1:40PM, LPA S. Smith conducted a safety inspection, and no immediate hazards were observed. Additionally, LPA Smith conducted interviews with Staff 1 (S1), Client 1 (C1), Client 2 (C2), and Client 3 (C3). Client 4 (C4) refused to be interviewed. On April 21, 2022, Community Care Licensing received a complaint alleging that minor is not provided clothing. Confidential interviews stated that the STRTP provides clients with $150.00 clothing allowance. Confidential interviews further stated that clients shop for clothing on a quarterly basis. A confidential interview stated that C5 did not have a lot of clothes. It was disclosed that C5 had been expedited a clothing allowance due to the lack of clothing. Confidential interview further stated that C5 did complain that C5 was being made fun of at school for wearing the same clothes. Confidential interview further stated that this was an issue at beginning of C5's placement at the STRTP. A confidential interview stated that it took the STRTP longer to issue a clothing allowance for C5 than other clients who were placed at the STRTP. A confidential interview stated that C3 was in placement at the STRTP for two months and had not been awarded a clothing allowance. During file review, LPA Smith noted in the STRTP's program statement on page 313 of Adequate clothing, STRTP provides $75.00 clothing allowance per month to each child and NMD. Based on confidential interviews the facility is not providing clients with the monthly $75.00 clothing allowance as stated in their program statement. Confidential interviews stated that the STRTP provides clients with a $50.00 monthly clothing allowance. Based on confidential interviews and file reviews, the preponderance of evidence standard has been met, and the allegation that C5 was not provided clothing is supported and proven by evidence. The facility is cited for violation of Short-Term Residential Treatment Facility (STRTP) Interim Licensing Standards Section 87022.1(a) PROGRAM STATEMENT Exit interview was conducted and a copy of this report along with the appeal rights was provided to Facility Manager Tracy Mitchell. On April 28, 2022, at 12:25PM Licensing Program Analyst (LPA) S. Smith initiated the investigation at Stella Maris Growth Center Short Term Residential Therapeutic Program (STRTP).At 1:40PM, LPA S. Smith conducted a safety inspection, and no immediate hazards were observed. Additionally, LPA Smith conducted interviews with Staff 1 (S1), Client 1 (C1), Client 2 (C2), and Client 3 (C3). Client 4 (C4) refused to be interviewed. On September 14, 2022, at 12:18PM, Licensing Program Analyst (LPA) Cynthia Urena interviewed staff 2 (S2) at the STRTP. On September 19, 2022, LPA Urena conducted telephone interviews staff (S3), staff 4 (S4), and one County Social Worker (CSW). During the investigation alleging that minor had access to dangerous objects, confidential interviews denied witnessing that C3 had a knife or other dangerous object while C5 was placed at the STRTP. A confidential interview stated that law enforcement conducted a search of C3's room and did not find a knife or other dangerous object in C3's belongings. Confidential interviews conducted denied having a dangerous or sharp object in possession. Confidential interviews added not seeing clients with dangerous objects. Another confidential interview stated that C5 had self-harming behaviors while in care and may have used sharp objects, however, the STRTP did not report these incidents to CSW on a timely manner. Regarding staff yelling at minor while in care or staff did not treat minor with dignity and respect. A Confidential interview stated that staff do not yell at clients but stated that staff can be disrespectful at times. Another confidential interview stated that staff do not yell at clients, but when clients are not listening, it is not unusual for staff to raise their voices. Confidential interview continued stating not witnessing staff being disrespectful to clients. Another confidential interview stated not hearing staff yelling at clients. The confidential interview added that when clients were loud staff do raise their voices to be heard. Other confidential interviews denied yelling at C5 and denied being disrespectful to C5 when placed at the STRTP. Another confidential interview stated that C5 did not report any concerns about the staff treatment at the STRTP. Based on confidential interviews, the allegations that C3 had access to dangerous objects, staff yells at C5 while in care, and that staff does not treat C5 with dignity and respect may have occurred, however, it is not supported or proven by evidence. There was not a preponderance of evidence to support or deny the allegations, therefore, these allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Facility Manager Tracy Mitchell.

Investigation Findings:
13On September 21, 2022, at 10:40AM, Licensing Program Analyst (LPA) Cynthia Urena met with Stella Maris Growth Center Short Term Residential Therapeutic Program (STRTP) Facility Manager, Tracy Mitchell to deliver the investigative findings for the above stated allegation. On April 21, 2022, Community Care Licensing received a complaint alleging that minor has access to dangerous objects, staff yells at minor while in care, staff does not treat minor with dignity and respect, and minor is not provided clothing. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: STELLA MARIS GROWTH CENTER IIFACILITY NUMBER: VISIT DATE: 09/21/2022

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


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Narrative:
facility is not taking measures to ensure the facility is free of insects. Based on the allegations that staff do not meet C1's medical, and educational needs a confidential interview stated that as of January 19, 2022, C1 had not seen a doctor. Confidential interviews revealed that there were challenges in keeping C1 at the school of origin due to transportation issues with the STRTP, and there was a delay on the part of the school district in enrolling C1 into a new school. There was no documentation provided to ensure that staff did enroll C1 within the allotted time. Confidential interviews indicated that there was a delay by program staff in getting C1 to see a doctor to refill medication. Confidential interviews indicated that the reason for a child not receiving medical attention was due to issues with medical insurance. Confidential interviews continued stating that for non-medical emergencies clients are taken to urgent care. Another confidential interview stated that staff keep record and document each time a client requests to go to the doctor. Another confidential interview stated that medical appointments often get rescheduled due to client refusal. Based on the allegation that staff are not following plan for therapeutic needs a confidential interview stated that clients are seen by the therapist once a week. Confidential interview continued stating that staff keep a log of those meetings. Confidential interview also stated that therapeutic services vary from client to client and there are times when clients refuse therapy. Another confidential interview stated that C1 had not seen the therapist. Another confidential interview stated not knowing how often clients see the therapist. It is unknown if C1 refused services or if services were offered to C1. Based on the allegation that C1 is not accorded dignity a confidential interview stated that staff make comments that result in clients feeling bad. More specifically, staff clapped their hand in front of C1's face when C1 was speaking. Confidential interviews stated that clients are accorded with dignity and respect by program staff, and when issues among clients or staff arise the house therapist facilitates meetings to address any concerns. Interviews indicated conflicting statements. Based on the allegations that staff are allowing smoking on facility grounds confidential interviews denied witnessing staff smoking; and that smoking on facility grounds is prohibited. Another confidential interview also denied seeing staff smoking at the facility. There were no witnesses to the incident. Continued on LIC C Page Based on the allegation that facility is not taking measures to ensure the facility is free of insect's confidential interviews stated seeing ants throughout the bathroom, and that the facility is prone to getting ants during summertime however, the facility does have someone who comes and sprays. Confidential interview also stated that clients are advised to eat all food at the kitchen and not in their rooms to keep ants from getting into client's bedrooms. It is unknown how long the insects were in the facility prior to having an exterminator out to the facility. Based on confidential interviews, the allegations that staff do not meet C1's medical needs, staff are not following plan for therapeutic services, staff do not meet C1's educational needs, staff do not accord dignity to C1, staff are allowing smoking on facility grounds, and facility is not taking measures to ensure the facility is free of insects. may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Facility Manager, Tracy Mitchell.

Investigation Findings:
13On November 10, 2022, at 9: AM, Licensing Program Analyst (LPA) Cynthia Urena met with Stella Maris Growth Center II Short Term Residential Therapeutic Program (STRTP) Facility Manager, Tracy Mitchell to deliver the investigative findings for the above stated allegations. On January 19, 2022, at 2: PM, Licensing Program Analyst (LPA) Sarah Smith initiated the investigation at the STRTP and interviewed three staff (S1 - S3) and two clients (C1, C2). On October 17, 2022, LPA Cynthia Urena continued an interview with one staff (S4), and on November 2, 2022, LPA Urena interviewed a County Social Worker (CSW). On January 10, 2022, Community Care Licensing received a complaint alleging that staff do not meet C1's medical needs, staff are not following plan for therapeutic services, staff do not meet C1's educational needs, staff do not accord dignity to C1, staff are allowing smoking on facility grounds,... UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Cynthia Urena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: STELLA MARIS GROWTH CENTER IIFACILITY NUMBER: VISIT DATE: 11/10/2022

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

met_with: Facility Manager, Tracy Mitchell