summary: Facility Evaluation

raw_content:
Narrative:
On April Licensing Program Analyst (LPA) Wendy Brown arrived unannounced at the facility and met with Joe Wylie, Administrator. The purpose of the visit was to conduct a Required Biennial Inspection of the facility. The last inspection that occurred was 11/04/2022. LPA utilized the CARE Tool to start the inspection. LPA conducted an inspection of the physical plant, and checked for all necessary requirements. The facility was clean and organized, and maintained an acceptable room temperature. The facility is a home like setting, with three client bedrooms, a large open plan kitchen/dining area, and a locked staff office. Each client had a closet and dresser in good repair. Mattresses and bedding were observed to be clean. Clients were able to decorate their rooms with their personal belongings. The backyard was free from hazards, and the pool was fenced with fencing previously approved by the Department. LPA observed the proper postings including: facility license, complaint hotline, client personal rights, and emergency disaster plan. The facility has two client bathrooms and one staff bathroom. Smoke alarms were in working order, fire extinguishers were current, and a first aid kit was fully stocked. LPA observed the kitchen to have at least 2 days of perishable food and 7 days of non-perishable food on hand. LPA observed client files and client medications were locked. LPA will return at a different date to conclude the inspection.


state: CA

facility_name: ENVIRONMENTAL ALTERNATIVES - BUTTE VALLEY

summary: Facility Evaluation

raw_content:
Narrative:
On 04/19/2024, Licensing Program Analyst (LPA) Wendy Brown arrived unannounced at the facility and met with Joe Wylie Administrator. The purpose of the visit was to finish the CARE Tool and interviews, and conclude the Required, Two-year Annual Inspection of the facility. The facility currently has six clients, with a licensed maximum capacity of six. Awake staff-to-client ratio from 7:00am to 10:00pm is 1:2 exceeding the state requirement, and the awake staff-to-client ratio from 10:00pm to 7:00am is 1:6. LPA reviewed 5 staff files. Staff files had completed criminal record clearances and all required initial and annual training. All First Aid and CPR certifications were up to date for staff. LPA interviewed all four staff on site at the time of the inspection. LPA reviewed five client files. All clients had signed Admission Agreements on file. Client files had completed Needs and Service Treatment Plans, signed by clients and staff. Needs and Service Plans detailed adequate supportive services the facility offers to the clients. Clients were current on CHDP physical exams and dental exams. One client is placed through foster care and five through Adoptions. Appropriate authorizations and the JV-220 were on file where applicable for psychotropic medications. LPA interviewed five clients. The facility has no outstanding fees. No citations were given on this date. An exit interview was conducted. A signed copy of this LIC-809 report was provided to the Administrator.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Joe Wylie, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Connie Goldie on 10/29/2024 at 10: AM. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPA Goldie met with Arthur (Joe) Wylie, Administrator and inspected the facility inside and out. LPA reviewed one of six (1/6) child's records and four/four (4/4) staff personnel files on site at the facility. LPA reviewed one of six (1/6) of child's psychotropic medications and medication records. LPA interviewed four of four (4/4) staff on site to discuss the facilities policies and procedures of operation. LPA interviewed one of six (1/6) children currently prescribed psychotropic medication. LPA provided a copy of this licensing report to Shari Mota, Supervisor. One technical violation was issued to the facility. This is not a deficiency. No deficiencies are being cited at this time. LPA conducted exit interview with Shari Mota, Supervisor.

met_with: Arthur Wylie Administrator Shari Mota Supervisor


summary: Facility Evaluation

raw_content:
Narrative:
On 5/8/ Licensing Program Analyst (LPA) Yesenia Vallejo and Misty Valencia arrived unannounced at the facility and met with Shari Mota, Facility Supervisor. The purpose of the visit was to conduct a Required Annual Inspection of the facility. The last Annual inspection for the facility was on 04/02/2025. LPA utilized the CARE Tool to complete the Annual inspection. The facility is licensed to provide treatment services for ambulatory children ages 7-14 years of age. The facility currently has 6 clients, one being a Regional Center placement. One client was present during the inspection.The facility is licensed for a maximum capacity of 6. Staff to client ratio is one to three. LPA conducted an inspection of the physical plant, and checked for all necessary requirements. The facility was clean and organized, and maintained an acceptable room temperature. The facility is a home like setting with a living room, three client bedrooms, a large open plan kitchen/dining area, and one locked staff office, with a separate building designated for the therapist. Each client had a closet and dresser in good repair. Mattresses and bedding were observed to be clean. Clients were able to decorate their rooms with their personal belongings. The backyard was free from hazards, safely fenced, with a variety of sports equipment accessible to clients. LPA observed the proper postings including: facility license, complaint hotline, client personal rights, and emergency disaster plan. continued on 809-C The facility has two client bathrooms and one staff bathroom. All were observed to be clean and fully functioning. Smoke alarms were in working order, fire extinguishers were current, and a first aid kit was fully stocked. LPA observed the kitchen to have at least 2 days of perishable food and 7 days of non-perishable food on hand, with additional food stored in the storage room. LPA observed client files and client medications were stored in a locked closet in the hallway. The facility has no outstanding fees. LPAs reviewed 5 client files, all clients were taking psychotropic medications and had current court documentation in files or parent authorization. Psychotropic medication logs for clients were written on separate Psychotropic Medication Administration Records. Clients were current on CHDP physical exams and dental exams. The client's Needs and Services Plan/Individual Program Plan, were complete and up to date. LPAs reviewed 5 staff files. Staff files had completed criminal record clearances and all required initial and annual training. First Aid and CPR certifications were up to date for all staff. Administrators Certificate was valid. LPA interviewed 2 staff on site. LPA interviewed 1 client on site. No citations were given on this date. A signed copy of this LIC-809 and LIC-809C, report was provided to the Facility Supervisor. An exit interview was conducted.

visit_type: Annual

met_with: Shari Mota, Facility Supervisor


facility_name: ENVIRONMENTAL ALTERNATIVES LOSH

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
S1, S2,S3 and S4 also stated that a stern, raised voice is only used if safety is a concern. Seven of nine confidential youth interviews corroborated that staff spoke appropriately to them. There are inconsistencies in the two additional interviews. One of the two was hearsay and the other could not be corroborated. Based on LPA's observations, and interviews which were conducted, the above allegations are determined to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No citations are being issued today, Exit interview was conducted with Facility Administrator, Gloria Losh at 2: PM. A copy of this report along with appeal rights were discussed and provided.

Investigation Findings:
13On 06/17/2022, Licensing Program Analyst (LPA), Connie Goldie met with Facility Administrator Gloria Losh at 2: PM and explained the purpose of the visit was to deliver complaint findings for the above allegation. LPA Shawndra Miles initiated the complaint at the above named facility on 11/08/2021and met with Facility Manager Dolores Martinez regarding a personal rights violation allegation. During the course of the investigation, LPA Goldie investigated the complaint that "Staff spoke inappropriate to resident in care." LPA Goldie conducted a records review of documentary evidence on 05/05/2022. LPA Goldie conducted a physical plant inspection of the home on 05/20/2022 and interviewed three staff. Additionally, nine foster youth, the facility administrator and the social worker were interviewed on 05/03/2022, 06/03/2022 and 06/10/2022. All staff collaborate that that they have not heard nor stated anything inappropriate to youth in care. Continued on LIC9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Connie Goldie LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: ENVIRONMENTAL ALTERNATIVES LOSHFACILITY NUMBER: VISIT DATE: 06/17/2022

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

report_type: Complaint Investigation

met_with: Facility Administrator Gloria Losh

complaint_status: unsubstantiated


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
The Department has investigated the complaint that Staff handled youth in a rough manner and staff threatened youth. C1 and S1 were by the front door entrance according to C2 and S1 tried placing C1 in a restraint. C1 confirmed S1 placed one hand on C1's shoulder and turned C1 around. C1, C2, and C3 confirmed that C1 wasn't threatened or handled roughly. C1 and C2 all confirmed C1 did not open the front door and was not pushed back into the home. C1, C2 and C3 confirmed that C1 was not chocked before or after the restrain. C1 stated "I thought, I was "I say stuff when I'm angry and don't mean it". C1 and C2 confirmed S1 had hands on C1 shoulders. C1 stated "I was not hurt". The reporting party did not observe any bruises or marks on the minor and the minor did not report any after the incident. Based on LPA's interviews which were conducted, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Exit interview conducted and no Title 22 regulations were cited during today's inspection. A copy of this report along with appeal rights was given to the Gloria Losh.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton conducted a visit on July 1, 2022, and LPA spoke with Gloria Losh, STRTP Administrator, to deliver findings of the investigation on the complaint allegations as stated. LPA Shelton informed the complaint investigation included a tour of the facility by LPA Shawndra Miles on 11/01/21. The initial 10-day complaint inspection was conducted by LPA Shawndra Miles, at the agency on 11/01/21 and LPA, obtained a recent copy of the LIC 500 and staff schedules. Interviews were conducted by LPA Mary Shelton, which included C1, C2, S1, S2 and the County Social Worker between 5/9/2022 and 5/12/2022. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Mary Shelton LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: ENVIRONMENTAL ALTERNATIVES LOSHFACILITY NUMBER: VISIT DATE: 07/01/2022

met_with: Gloria Losh


summary: Complaint Investigation - Substantiated - 1 deficiency

raw_content:
Narrative:
The Department has investigated the complaint that Staff improperly restrained youth. C1 was heading towards the front door entrance to run away and S1 was following behind C1. S1 was talking to C1 as C1 was trying to leave the home. C1 turned around and called S1 a "bitch" and attempted to hit S1. S1 then attempted to place C1 in a Small Child Restraint. C1 confirmed S1 placed one hand on C1's shoulder and turned C1 around. C2 and S1 stated C1 let her body go limp during the restrain and went to the floor. Protocol was not followed as outlined in the Program Statement by staff which resulted in a youth being placed in an improper restraint. The Program Statement states "Physical interventions will be employed when a child is in immediate danger of harming her/self or other and when other less restrictive interventions have failed, and a "Restraint" is defined as: The use of trained staff members to hold a young person to contain acute physical behavior" the restrain was not executed properly which resulted in C1 going to the floor. Also, staff did not follow the Program Statement regarding "Staff will first employ protective interventions (releases, deflections, proximity, and protective stance) when a child attempts to physical harm to staff or peers. Staff did not allow enough space between C1 therefore, the staff was not implementing proximity and a protective stance which resulted in a improperly restraint. The youth was restrained for behavior that did not present an imminent danger for injuring self or others which poses a potential Health, Safety, or Personal Rights risk to clients in care. As a result of the interviews conducted, documentation reviewed and investigation conducted, the allegation that staff improperly restrain youth is SUBSTANTIATED at this time meaning that the allegation is valid because the preponderance of the evidence standard has been met. Facility cited for violation of California Code of Regulations, Title Division Six, regulation 87095.00(d) General Provisions: All children placed in a short-term residential therapeutic program have the right to be free from the use of restraints imposed as a means of coercion, discipline, convenience, or retaliation by staff An exit interview was conducted with Gloria Losh, STRTP Administrator, a copy of the report and appeal rights were provided. No title 22 regulations were cited during today's inspection.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton conducted a visit on July 1, 2022, and LPA spoke to Gloria Losh, Administrator to deliver findings of the investigation on the complaint allegation as stated. LPA Shelton informed the complaint investigation included a tour of the facility by LPA Shawndra Miles on 11/01/21. The initial 10-day complaint inspection was conducted by LPA Shawndra Miles, at the agency on 11/01/21 and LPA, obtained a recent copy of the LIC 500 and staff schedules. Interviews were conducted by LPA Mary Shelton, which included C1, C2, C3, S1, S2 and the County Social Worker between 5/9/2022 and 5/12/2022. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Mary Shelton LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: ENVIRONMENTAL ALTERNATIVES LOSHFACILITY NUMBER: VISIT DATE: 07/01/2022

Deficiencies:
87095.00(d): All children placed in a short-term residential therapeutic program have the right to be free from the use of restraints imposed as a means of coercion, discipline, convenience, or retaliation by staff.

met_with: Gloria Losh, STRTP Administrator

complaint_status: SUBSTANTIATED

title: General Provisions


raw_content:
Narrative:
No title 22 regulations were cited during today's visit. An exit interview was conducted, and a copy of this report, and appeal rights were left with Gloria Losh, Administrator, whose signature on this form confirms receipt of these documents.

Investigation Findings:
13Licensing Program Analyst (LPA) Shawndra Miles conducted an unannounced inspection at the agency on 08/29/2022 at TIME to deliver complaint allegation findings. LPA met with Gloria Losh, Administrator and discussed the above allegations. LPA conducted confidential interviews with five youths and four adults. The interviews were consistent that during their bedroom routine, the youth had a physical altercation with another youth in their bedroom, while in care. However, there is not enough evidence to show there was a lack of supervision and/or staff could have prevented the incident from occurring. Based on LPAs observations and interviews which were conducted and record review(s), although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Shawndra Miles LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NO. Cal Cr/res., Natomas Park Dr., STE FACILITY NAME: ENVIRONMENTAL ALTERNATIVES LOSHFACILITY NUMBER: VISIT DATE: 08/29/2022

met_with: Gloria Losh, Administrator


raw_content:
Narrative:
During the investigation LPA Ajaero interviewed the administrator and facility managers on 1/19/23 and learned that staff accompanied FY1 to the hospital and stayed with FY1 till the doctor directed the staff to leave. Staff was directed to leave because the hospital had a sit-in staff that remained with FY1. Staff stated that it was based on this reason that Staff presence was no longer required by the hospital. On 1/20/23, the Program Director provided the facility policy. The policy did not have any requirement that the staff should stay at the hospital with clients when they are taken for psychiatric treatment. LPA Ajaero was informed by LPA Michael Almaraz that during LPA's visit on 2/9/23, FY1 appeared to be under the influence and could not be interviewed by the LPA. On 2/2/2023, Reporting Party stated that at the time of FY1's evaluation, FY1 was attended to by a hospital sitter and that Hospitals in San Joaquin County have different protocols regarding if a legal guardian, referring to Facility staff, has to be present in the ER. Therefore, he could not firmly state whether the Staff was required or not. Additionally, reporting party stated that due to the emergent need for a mental health evaluation on the client, it was necessary to complete the evaluation without a legal guardian present. In addition, the Administrator denied any knowledge of any staff making inappropriate comments towards FY1. On 1/19/23, LPA interviewed the staff and they denied making the alleged statement. Lastly, LPA Ajaero made several attempts to interview FY1. FY1 is not available to respond to questions at this time because FY1 has been hospitalized with no definite day of release. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview was conducted. A copy of the report and appeal rights were provided to the Administrator, Gloria Losh.

Investigation Findings:
13On 3/30/2023, Licensing Program Analyst, (LPA) Uchenna Ajaero made an unannounced complaint investigation visit to Environmental Alternatives Losh to deliver findings for this investigation. LPA Ajaero met with Gloria Losh the Administrator and informed her of the reason for the visit. During the investigation, LPA Jean Stidman initially conducted a visit to the facility on 9/23/22. On 1/19/23, LPA Ajaero visited the facility and met with the Administrator and obtained copies of incident reports, needs and services plan, placement reports, staff schedule and roster of the facility and daily staff assignments for the period of the incident. LPA Ajaero was informed that the FY1 has been moved to another facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Uchenna Ajaero LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: ENVIRONMENTAL ALTERNATIVES LOSHFACILITY NUMBER: VISIT DATE: 03/30/2023

met_with: Gloria Losh, Facility Administrator


raw_content:
Narrative:
The Department investigated the complaint that staff lock the refrigerator. C1 stated there was a child lock placed on the middle drawer of the refrigerator in the kitchen. The refrigerator has three different ways to access opening; two top doors that swing open, a middle drawer that pulls out and a bottom drawer that pulls out and opens. During confidential interviews the administrator, three staff and three clients stated that they have never seen a lock on the refrigerator door in the kitchen. A former client and mother who works for CPS also stated that there was not a lock on the refrigerator door. LPA Shelton observed the refrigerator in the kitchen and to place a child lock on the middle drawer would not prevent the drawer from opening. Based on the investigation, records reviewed, and interviews conducted, the complaint finding is UNSUBSTANTIATED at this time meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No Title 22 deficiencies were cited. LPA Shelton provided a copy of report along with appeal rights were discussed.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton arrived at the home to conduct an unannounced complaint investigation inspection on 7/30/2024 at 11: AM. LPA Shelton spoke with Gloria Losh, Administrator, to discuss the findings of the complaint investigation and allegation stated above. LPA Shelton informed the Administrator this case was investigated by LPA Shelton. The initial 10-day complaint investigation inspection was conducted by LPA Mary Shelton at the home on 7/10/2024. Copies of facility documentation were provided to LPA Shelton included: LIC 500 and a current client roster. Confidential interviews were conducted with the reporting party, administrator, four clients, three staff and a former client's mother between 7/10/24 and 7/29/2024. Records review of documents and photos obtained was completed on 7/10/2024. Continued on LIC9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Mary Shelton LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ENVIRONMENTAL ALTERNATIVES LOSHFACILITY NUMBER: VISIT DATE: 07/30/2024

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


raw_content:
Narrative:
It was alleged that staff members S1, S2, and S4 pushed the child, pulled her by her arm, and threw a water bottle at her. Confidential interviews revealed that during the child's two week stay, she had many physical altercations with another youth in care, and that staff had put hands on her once when attempting to prevent a physical fight between clients. An Incident Report (IR) was sent in by the facility on 9/12/24 describing an incident where S4 held C1's wrists for less than 20 seconds when she was going in to beat up another client and was also swinging at the staff member. Confidential interviews with staff revealed that C1 was threatening to hit C2 with a water bottle, so staff collected all water bottles in the facility, and locked them up to prevent this from happening. In an interview with C1, when asked about an incident with a water bottle, the youth stated that she was the one who tried to, "hit C2 upside the head with a water bottle". C1 stated, on another occasion, S1 told her to 'get out of the way' and pushed her. C1 stated S3 was a witness. S1 stated, no staff had ever pushed C1, and S3 stated she never saw anyone push C1 either, resulting in conflicting information. This Department has investigated the complaint alleging that the minor is being physically abused in care. We have found that the complaint is Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with the Administrator, Gloria Losh. A copy of this report, and appeal rights were given.

Investigation Findings:
13On Monday, October 28th, 2024, Licensing Program Analyst (LPA) Brittany Crass, made an unannounced complaint investigation inspection at the facility, to deliver findings for the allegation listed above. LPA met with the Facility Administrator, Gloria Losh, who assisted with the inspection. LPA conducted the initial-10 day complaint investigation at the Facility on 9/20/24. Between 9/20/24 and 10/21/24, LPA reviewed C1's file, and interviewed the Administrator, four staff members, and the Agency Social Worker/Clinician. On 10/17/24, LPA Karen McGee conducted a collateral interview at James Penny House Facility to interview C1. It was alleged that the minor is being physically abused while in care. (Continued on LIC 9099-C). UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Hall LICENSING EVALUATOR NAME: Brittany Crass LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: ENVIRONMENTAL ALTERNATIVES LOSHFACILITY NUMBER: VISIT DATE: 10/28/2024


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Jean Stidman on 3/8/22 at 10:00am . During the inspection, LPA Stidman met with Gloria Losh Administrator and inspected the facility inside and out. LPA reviewed two child's records on site at the facility at 10:00am LPA reviewed three staff personnel files on site at the facility at 10:00am LPA reviewed two child's psychotropic medications and medication records at 10:00am LPA interviewed three staff on site at 10:00am. LPA interviewed two children currently taking psychotropic medication at 3:00pm. LPA conducted exit interview with Gloria Losh Administrator at 4:15pm. LPA provided the Summary Report to Gloria Losh Administrator upon completion. No deficiencies are being cited at this time. LPA conducted exit interview with Gloria Losh Administrator at 4:15pm

met_with: Gloria Losh Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 5/7/ Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced case management inspection at the facility and met with Administrator Gloria Losh and Clinician Roxanne Rose who assisted with the inspection. CCL received an incident report dated 4/29/2026. LPA is conducting this case management inspection to gather more information about the incident and to evaluate the actions taken. LPA interviewed the Clinician and Administrator about the incident. Based on additional information obtained, LPA found that the facility acted appropriately. This case management is closed. An exit interview was conducted with Administrator and a copy of this report was provided to her.


facility_name: ETTIE LEE-ROBERTSON MEMORIAL HOME

raw_content:
Narrative:
inappropriate behaviors were conducted. Information obtained from confidential interviews denied the allegation. It was reported that Client #2 did make inappropriate comments regarding other clients' family members, but never was observed to inappropriately interact with clients physically. Information from confidential interviews stated that supervision was adequate and there were no concerns. Information obtained from County Probation Officer stated the request for Client #2's removal was the initial information provided regarding any concerns. County Probation Officer stated she was not granted much information regarding the alleged incidents due to confidentiality. County Probation Officer stated she had no concerns regarding the staff or supervision provided. Based on interviews and information obtained, staff did not adequately supervise residents resulting in inappropriate touching, may or may not have occurred; therefore, the allegation is unsubstantiated at this time.

Investigation Findings:
13On December 22, 2021, at 11: AM, Licensing Program Analyst (LPA) Jazmond Harris met with Administrator, Steve Lechuga to deliver the findings for the investigation pertaining to the listed allegation. LPA Harris initiated the investigation on June 17, 2021 and interviewed Facility Manager and four out of five Clients (See Confidential Names List (LIC 811) dated December 22, 2021). During the investigation, LPA Harris conducted interviews with Administrator, Staff Member, County Probation Officer, and Client #2. On June 16, 2021, Community Care Licensing (CCL) received information which stated staff did not adequately supervise residents, resulting in inappropriate touching. It was reported that Client #2 inappropriately interacted with Client #3. It was stated that Client #2 pulled their pants down and sat on Client #3's face. Information from administration and staff stated that Client #2 was observed to communicate inappropriately with clients and staff, which caused for redirection. Information obtained stated there were not any incidents observed or advised of which deemed there was inappropriate touching. Staff did state that clients would be told to stay out of each other's rooms to ensure no inappropriate behaviors were conducted. UnsubstantiatedEstimated 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: ETTIE LEE-ROBERTSON MEMORIAL HOMEFACILITY NUMBER: VISIT DATE: 12/22/2021

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

met_with: Administrator-Steve Lechuga


raw_content:
Narrative:
Additionally, a former employee staff #1 (S1) could not be reached for comment after multiple attempts made by the Investigator for an interview. On December 14, 2023, Community Care Licensing (CCL) received a complaint alleging S1 is providing alcohol to minors while in care, S1 is providing marijuana to the minors while in care, S1 is providing nicotine products to the minors while in care, and minors provided S1 their allowance to buy nicotine products. During the investigation there was no corroborating evidence to support the allegations. Although CCL received detailed information that S1 provided alcohol, marijuana, and nicotine products to clients in care during transportation services that were facilitated by S1, and that clients provided S1 with their allowances to buy these products. The information provided to the Investigator regarding these allegations was inconsistent. Confidential interviews deny the allegations while another confidential interview maintains that the allegations involving S1 are true. Confidential interviews further reported that facility staff inquired about these allegations with S1 prior to resignation and the allegations were denied. A confidential interview reported that when reviewing receipts of the client's allowances there was nothing suspicious observed that would indicate that allowances were spent on alcohol, marijuana, or nicotine products. There were no other known witnesses to the allegations and S1 could not be reached for comment. Based on confidential interviews, and record review the allegations that staff is providing alcohol to minors while in care, staff is providing marijuana to the minors while in care, staff is providing nicotine products to the minors while in care, and minors provided a staff member their allowance to buy nicotine products, may have happened or are 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, Angelita Arellano.

Investigation Findings:
13On March 14, 2024, at 9: AM, Licensing Program Analyst (LPA), Cynthia Urena met with Ettie Lee-Robertsons Memorial Home Short Term Residential Therapeutic Program (STRTP) Facility Manager, Angelita Arellano to deliver the investigative finding for the above stated allegations. On December 27, 2023, at 10: AM, Licensing Program Analyst (LPA) Cynthia Urena initiated the investigation at the STRTP and collected pertinent documents from the STRTP staff and client files. A Health and Safety inspection of the facility was conducted with the Administrator and no deficiencies were observed. LPA advised the Administrator that Peter Zertuche with the Community Care Licensing Division (CCLD) Investigations Branch (IB) would be leading the investigation. Investigator, Zerturche interviewed three county staff members, four facility staff members (S2, S3, S4, S5), and three clients (C1, C2, C3). Investigator, Zertuche attempted interviews with three additional clients (C4, C5, C6) and clients declined interviews. (**Continued on LIC C**) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap 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: ETTIE LEE-ROBERTSON MEMORIAL HOMEFACILITY NUMBER: VISIT DATE: 03/14/2024

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

met_with: Facility Manager, Angelita Arellano


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Narrative:
It was also reported that S3 did not appreciate C1 making the report threats to Community Care Licensing (CCL) and to be careful what was said to the therapist. Lastly, it was reported that S3 said to C1 to get over it and laughed at C1. Confidential interview gave conflicting statements: S4 did not request C1 to return to the facility to pick up school supplies, while another interview states that it did occur. Confidential interviews revealed that S3 speaks to C1 in a demanding tone of voice and may be considered as threatening or inappropriate. Some interviews entailed S3 and other staff to be courteous and respectful and would never provoke, threaten, and speak to the clients inappropriately. There were no witnesses to the alleged incident. Based on inconsistent confidential interviews, the allegation that staff provokes C1 in care, staff threatened C1 in care, and staff inappropriately spoke to C1 in care may have occurred, however, is not supported or proven by evidence. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with appeal rights was provided to Ettie Lee Robertson Memorial Homes Short Term Residential Therapeutic Program (STRTP), Steve Lechuga, Administrator.

Investigation Findings:
13On 04/18/2024 at 12: PM, Licensing Program Analyst (LPA) Sarah Lo met with Steve Lechuga, Administrator, to deliver the finding for the above complaint allegation at Ettie Lee Robertson Memorial Homes Short Term Residential Therapeutic Program (STRTP). On 08/09/23, LPA inspected the facility's physical plant, and no immediate health and safety hazards were observed. The investigation included interviews with four staff members (S1-S4) and two clients (C1 & C5), clients (C2, C3, C4 & C6) refused to be interviewed. Clients' Needs and Services Plans and case notes were reviewed. On July 31, 2023, Community Care Licensing received an allegation that staff provokes a foster child (C1) in care, staff threatened a foster child (C1) in care and staff inappropriately spoke to foster child (C1) in care. Specifically, it was reported that S4 asked C1 to get school supplies before going on a visit and if not C1 was not able to go on the visit. (continued on LIC 9099c) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Sarah Lo LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: ETTIE LEE-ROBERTSON MEMORIAL HOMEFACILITY NUMBER: VISIT DATE: 04/18/2024

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

met_with: Steve Lechuga, Administrator


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**Continued From Previous Page** minors to watch pornography while in care. Specifically, it was reported RC5 allowed the minors (C1-C6) to watch pornography. Confidential interviews and documentation review provided conflicting statements regarding C1-C6's exposure to pornography. Therefore, confidential interviews and documentation review could not confirm or dispute the allegation that staff allowed minors to watch pornography while in care. CCL received a second allegation alleging staff inappropriately pushed a minor. Specifically, it was reported that RC5 pushed C1. Confidential interviews provided conflicting accounts of an incident involving RC5 and C1 and if the incident involved any physical contact between RC5 and C1. Record review was unable to provide any evidence of an incident occurring between RC5 and C1. Conflicting statements and record review could not confirm or dispute staff inappropriately pushed a minor in care. A third allegation alleging staff inappropriately transported the minors while in care was received by CCL on July 31, 2024. Specifically, it was reported RC5 would speed and use RC5's cell phone while transporting minors (C1-C6). Confidential interviews and documentation review provided conflicting evidence of RC5's use of their cell phone and RC5's travel above the posted speed limit while transporting clients. Confidential interviews provided conflicting statements regarding the speed in which RC5 drove while transporting clients. Additionally, confidential interviews confirmed RC5's use of RC5's cell phone while transporting however, could not confirm or dispute if cell phone usage was for directions while driving or for another purpose. Therefore, the allegation that staff inappropriately transported minors could not be confirmed or disputed. Based on confidential interviews and documentation review the preponderance of evidence standard has not been met and the allegations that, Staff (RC5) allowed the minors (C1-C6) to watch pornography while in care, Staff (RC5) inappropriately pushed a minor (C1), and Staff (RC5) inappropriately transported the minors (C1-C6) while in care, may have happened or are valid, but there is not a preponderance of evidence to prove that the alleged violations occurred. 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 Ettie Lee- Robertson Memorial Home, Short Term Residential Therapeutic Program (STRTP), Angelita Arellano, Facility Manager.

Investigation Findings:
UnsubstantiatedEstimated Days of Completion: 90-Days Estimated Days of Completion: 90-Days Estimated Days of Completion: 90-Days

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

met_with: Angelita Arellano, Facility Manager


summary: Facility Evaluation

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Narrative:
On the above date, Licensing Program Analysts (LPAs), Jazmond Harris and Val Wilson conducted an annual required inspection. LPAs met with Administrator, Steven Lechuga. LPAs began a physical plant inspection at 9: AM 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, books, and games were observed for client's recreation time. All facility smoke 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 staff office. Chemicals/poisons and sharp objects are locked and stored in the staff office. First Aid Kits are also stored in the staff office and are complete. Licensee has provisions for contraceptives to be held in individually locked containers by clients. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client's bathroom was deemed safe. The facility has a building in the rear, which has three rooms and a bathroom area. The building is not utilized to currently house clients. Facility has cameras in common areas of the facility. The facility has a waiver on file to use the cameras and are meeting the terms and conditions. Facility has a pool which is appropriately fenced and secured with a wrought iron exterior. The enclosure was measured to be over 5 feet tall, with a self-latching gate that swings outward. Per Administrator, no firearms or weapons are allowed in the facility. Facility appears to be meeting the terms and conditions of their license. Administrator 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. The facility employs one social worker, one therapist, four facility managers, and four direct care staff. Licensee has obtained National Accreditation through Council On Accreditation. The Accreditation is valid through February 29, 2024. Annual Fees are current. LPAs reviewed five client files. All required documents were present in the files with required dates and signatures. LPAs also reviewed medication logs, JV-220s, and medication. Client #1 and Client #4's needs and service plan will be sent to LPA Harris for review at a later time. Personnel files are maintained off-site at the corporate office in Baldwin Park, but the facility did have employee documents available. LPAs reviewed six staff files. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. LPAs reviewed the staff's first Aid/CPR certificates and proof of TB tests LPA discussed the following with the Administrator: Incident reporting, including incidents related to Assembly Bill 388, law enforcement contacts as well as incidents involving emergency interventions. LPA discussed procedures for Child and Family Team (CFT) meetings, including an overview of required Core Services and Supports. Based upon the inspection of facility records and observation, the Licensee appears to be meeting CFT and Core Services/Supports requirements. An exit interview was conducted. A copy of the report will be provided to the facility.

met_with: Administrator-Steven Lechuga


summary: Facility Evaluation

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Narrative:
On April 28, 2023 at 09: AM, Licensing Program Analyst (LPA), Sarah Lo conducted an annual inspection at Ettie Lee-Robertson Memorial Home located at Liveoak Canyon, Redlands, CA 92373. LPA met with STRTP Administrator, Steve Lechuga. LPA began a physical plant inspection at 09: AM 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, books, and games were observed for client's recreation time. All facility smoke 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 staff office. Chemicals/poisons and sharp objects are locked and stored in the staff office. First Aid Kits are also stored in the staff office and are complete. Licensee has provisions for contraceptives to be held in individually locked containers by clients. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client's bathroom was deemed safe; bathroom #1 measured at 107.2 degrees and bathroom #2 measured at 106.3 degrees. The facility has a building in the rear, which has three rooms and a bathroom area. The building was utilized as separation rooms during COVID time but is not utilized to currently house any clients. Facility has cameras in common areas of the facility. The facility has a waiver on file to use the cameras and are meeting the terms and conditions. Facility has a pool which is appropriately fenced and secured with a wrought iron exterior. The enclosure was measured to be over 5 feet tall, with a self-latching gate that swings outward. Per Administrator, no firearms or weapons are allowed in the facility. Facility appears to be meeting the terms and conditions of their license. (Continued on LIC 809-C) Administrator, Steve Lechuga is present at the facility a minimum of 20 hours a week, as verified by staff schedule and interviews. Appropriate staff/client ratios were verified during this inspection. The facility employs one social worker, one therapist, four Facility Managers and six Residential Counselors. Licensee has obtained National Accreditation through Council on Accreditation (COA). The Accreditation is valid through 02/29/2024. Licensing fee payments have been paid and there is currently a balance of $0. LPA reviewed five client files. All required documents were present in the files with required dates and signatures. LPA also reviewed medication logs, JV-220s, and medication. Client #1 (See Confidential Names List (LIC 811) dated April 28, 2023, is missing the tuberculosis (TB) test result. Per CCR 80069 (c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases. Personnel files are maintained off-site at the corporate office in Baldwin Park, but the facility did have employee documents available. LPA reviewed five staff files. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. LPA reviewed the staff's first Aid/CPR certificates and proof of TB tests LPA interviewed two staffs and one clients; there were two clients available but one had to leave to therapy before LPA was able to interview him. Clients interviewed deemed that their needs were being met and they feel safe and secure in the facility. Staff and clients have no issues or concerns regarding the facility. An exit interview was conducted. A copy of the this report (LIC 809 and LIC 809-C), the LIC 809-D and appeals right is provided to the STRTP Administrator, Steve Lechuga

met_with: Steve Lechuga, STRTP Administrator


summary: Facility Evaluation

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Narrative:
On January 26, 2024 at 11:00 am Licensing Program Analyst (LPA), Emina Preciado, conducted a visit at Ettie Lee- Robertson Memorial Home, Short Term Residential Therapeutic Program (STRTP). LPA met with Angelita Arellano, Facility Manager. The purpose of the visit was to conduct a confidential interview with a client for an investigation. Exit interview was conducted and a copy of the this report was provided to facility representative.


summary: Facility Evaluation

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Narrative:
On January 23, 2025, at 9: AM Licensing Program Analyst (LPA), Jason Dalton, met with Ettie Lee Robertson Memorial Home (STRTP), Facility Manager Angelita Arellano, to initiate a case management - incident inspection. Information obtained by Community Care Licensing (CCL) revealed a concern of possible personal rights violation occurring at the facility on January 13, 2025. The purpose of the inspection is to obtain additional information, conduct interviews and gather documentation to assist with the case management. A copy of this report was provided to Ettie Lee Robertson Memorial Home (STRTP), Facility Manager Angelita Arellano.

met_with: Facility Manager Angelita Arellano


summary: Facility Evaluation

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Narrative:
On May 20, 2026, at 01: PM, Licensing Program Analyst (LPA) Raina Perez-Diaz, arrived unannounced to Ettie Lee Home- Robertson Memorial Home Short Term Residential Treatment Program (STRTP) and met with Sydney Vahle, Facility Administrator, for the purpose of conducting an interview related to a complaint not at this facility. One interview was conducted. A copy of this report and LIC- 811 were provided to Facility Administrator, Sydney Vahle.

met_with: Administrator- Sydney Vahle


facility_name: ETTIE LEE HOME-FONTANA HOME

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Narrative:
confidential interviews revealed that there was no evidence to prove the allegation did occurred. Community Care Licensing also received an allegation that staff (S4) threaten minor (C1) in care. Consistent confidential interviews disclosed that staff haven't threaten clients (C2, C3, C4, & C7) at all. Other confidential information received stated that S4 threaten C1 occurred in the home. Confidential interviews reported that a staff heard a client (unknown) saying a staff (unknown) yelled at them. Confidential interviews reported that clients (C2, C3, C4, & C7) haven't seen any staff threaten C1. Confidential interviews reported that clients (C2, C3, C4, & C7) don't feel scared living in the home. There is no sufficient evidence that S4 made threats toward C1 while C1 is in placement. Community Care Licensing also received an allegation that staff (S4) lock minor (C1) out of facility. Confidential interviews reported that C1 went outside to play basketball. S4 was preparing dinner. Another staff was outside briefly and came inside to use the bathroom. C5 walked by and locked the door. As C1 was returning to the house, S4 did not immediately open the door because S4 was washing poultry off hands that was for dinner. Once S4 finished washing hands, then S4 opened the door. Other confidential interviews reported that C1 walked to the side door to go back inside the house and S4 locked the door while S4 watched C1 approached the door. Additional, confidential interviews reported that the clients (C2, C3, C4, & C7) deny being locked out the house. Community Care Licensing also received an allegation that minor (C1) not accorded privacy while in care. Confidential interviews reported that clients (C1, C2, C3, C4, & C7) are given privacy to shower and changed clothes. Confidential interviews reported that staff checks on clients every 15 minutes and knock on the client's bedroom doors before they enter the bedrooms. The evidence collected during this investigation was not sufficient to substantiate the allegations against the staff. LPA received lack of details and information regarding the allegations. Based on confidential interviews, the allegations may have occurred, however; is not supported by evidence. Therefore, the allegations are unsubstantiated. A copy of this report and appeal rights were provided to Patrick Williams, STRTP Administrator.

Investigation Findings:
13On December 28, 2021 at 11:35 am, Licensing Program Analyst (LPA), Cheraki Davis met with Patrick Williams, Short Term Residential Therapeutic Program (STRTP) Administrator to deliver the finding for the above complaint allegations. On 09/22/2021 at 11:25am, LPA conducted a safety inspection and no immediate safety hazards were observed. The investigation was conducted by Special Investigator Brittany Hudec of the Community Care Licensing (CCL) Investigations Bureau. Investigation included interviews with clients (C1, C2, C3, C4, C5, & C7), staff (S1, S2, S3, & S4), and Program Manager. Incident report was reviewed. LPA was unsuccessful with interviewing client 6 (C6) due to C6 not currently residing at the facility. On September 20, 2021, Community Care Licensing received an allegation which stated staff (S3) inappropriately touched minor (C1 & C5) while in care. Confidential interviews deny that there was any inappropriately touching in the home while other confidential information received stated that the inappropriately touching occurred in the home when S3 woke C1 and C5 up in the morning. Other confidential interviews reported that C1 and C5 denied being touched on their private parts. Additional UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Cheraki Davis 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: ETTIE LEE HOME-FONTANA HOMEFACILITY NUMBER: VISIT DATE: 12/28/2021

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

met_with: Patrick Williams, Administrator


raw_content:
Narrative:
in a timely manner, Lack of supervision resulting in minors smoke marijuana on the premises, and Facility staff does not safeguard minors' belongings. Confidential interviews revealed that C7 refused medical attention on several occasions. Confidential interviews revealed C7 did request medical attention, but when the appointments would come the C7 often refused to go. LPA Smith could not prove that on all occasions the client requested medical attention that they refused to go. Confidential interviews revealed that there was an incident where C7 and Staff 1 were in an altercation. Confidential interviews disclosed that C7 was offered medical attention but LPA was unable to interview C7 to obtain specific details regarding the allegation. Regarding the allegation that minors are smoking on facility grounds due to lack of supervision, confidential interviews revealed that the facility staff does address any appearance of the clients smoking. Confidential interviews revealed that the procedure to follow if a client is smoking is to ask them to put it out, and if the client refuses then the staff monitors the client to ensure that they are not in any immediate danger. Confidential interviews of the clients revealed that the staff does not allow the clients to smoke at the facility while other confidential interviews revealed that the clients in care smoke at the facility without being redirected. LPA received inconsistent information regarding the allegation. Regarding the allegation that staff does not safeguard (Client 1) belongings, confidential interviews revealed that inventory is taken upon client entry into the facility. Documentation showed that clients in care had property stolen and was reimbursed for the items. It was not clear whether the items were kept in a manner that was appropriate. LPA received inconsistent information regarding the allegation. Regarding the allegation that staff mismanages minors' medication, during the course of the investigation LPA received documentation showing that C7 did receive medication according to the prescribed manner. No evidence was collected to support that C7 received medications with adverse interactions. C7 could not be interviewed to gain specific details about this allegation. Based on confidential interviews and record review, the allegations that Staff did not seek medical attention for minor in a timely manner, Lack of supervision resulting in minors smoke marijuana on the premises, Facility staff does not safeguard minors' belongings, and Staff mismanages minors' medication may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. ------continued on the next page----- A copy of this report and Appeals Rights were provided and explained to Facility Administrator Williams. On 11/18/2021, Community Care Licensing received allegations that staff are not reporting incidents accurately, staff engaged in a physical altercation with minor, facility is in disrepair, and facility poses a safety hazard to minors in care (C1, C2, C3, C4, C5, C6, & C7). Confidential interviews revealed that there was a Serious Incident Report involving Law Enforcement dated 12/02/2020 that was submitted as a "normal" notification and left out details regarding what actually occurred. Consistent confidential information received revealed that the serious incident report was not reported accurately and did not include pertinent details of the incident. Confidential interviews revealed that a staff member did engage in an altercation with a client in care (C7) which lead to the staff member (S1) performing a one-person restraint on C7. Confidential interviews revealed that S1 placed C7 in a restraint after being physically attacked by C7. Consistent confidential interviews revealed that the roof of the facility was leaking in the game room. During the health and safety inspection on 10/26/2021, LPA noted that the walls in bedrooms two and three needed to be painted because there were areas where the paint is peeling. In addition, the side door to the facility had a piece of cloth in it to prevent the facility alarm from going off when the wind blew. LPA observation and confidential interviews revealed that the outside weight benches had no locks to hold the weights in place while the clients exercised. Based on confidential interviews and record review, the preponderance of evidence standard has been met and the allegations of staff are not reporting incidents accurately, staff engaged in a physical altercation with minor, facility is in disrepair, and facility posed a safety hazard to minors in care (C1, C2, C3, C4, C5, C6, & C7) are substantiated which poses a health, safety and personal rights risk to clients in care. Facility is cited for violations of Short-Term Residential Therapeutic Program Interim Licensing Standards (ILS) , Version 3.1, 87072(d)(11) Personal Rights and (ILS) 87088. Outdoor Activity Equipment in addition to California Code of Regulations (CCR) 80012(a) False Claims and 80087(a) Buildings and Grounds. An exit interview was conducted and a copy of this report, LIC 811 and appeal rights were given and explained to Patrick Williams, Facility Administrator.

Investigation Findings:
13On December 28, 2021 at 2:30 p.m., Licensing Program Analyst (LPA), Sarah Smith, conducted an in person inspection with Patrick Wiilliams, Facility Administrato of Ettie Lee Home- Fontana Home to discuss the findings for the above stated allegations. On 10/26/2021 at 9:40 p.m., LPA conducted a health and safety inspection and safety concerns observed are being addressed in a case management. The above allegations involved clients (C1, C2, C3, C4, C5, C6, C7). During the course of investigating the allegation, LPA Smith conducted confidential interviews with clients (C2, C4, C5) and staff (S1, S2, S3, S4, S5, and S6) . Client 1 (C1), Client 3 (C3), and Client 6 (C6) refused to be interviewed. LPA attempted to interview C7, however, C7 no longer resides at the facility and current whereabouts are unknown at this time. LPA reviewed reports and the records for the STRTP, staff, and clients. --------continued on the next page-------- 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 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE This is an official report of an unannounced visit/investigation of a complaint received in our office on 10/18/2021 and conducted by Evaluator Sarah Smith PUBLICCOMPLAINT CONTROL NUMBER: 19-CR- FACILITY NAME:ETTIE LEE HOME-FONTANA HOMEFACILITY NUMBER: ADMINISTRATOR:BECK, MELANIEFACILITY TYPE: ADDRESS: CITRUS AVENUETELEPHONE: (909) 823- CITY:FONTANASTATE: CAZIP CODE: CAPACITY:10CENSUS: 8DATE: 12/28/ UNANNOUNCEDTIME BEGAN: 02: PM MET WITH:Patrick Williams, Facility AdministratorTIME COMPLETED:03: PM 9Staff did not seek medical attention for minor in a timely manner Lack of supervision resulting in minors smoke marijuana on the premises Facility staff does not safeguard minors' belongings Staff mismanages minors' medication INVESTIGATION FINDINGS: 13On December 28, 2021 at 2:30 p.m., Licensing Program Analyst (LPA) Sarah Smith met with Ettie Lee Home-Fontana Home Short-Term Residential Therapeutic Program (STRTP) Facility Administrator, Patrick Williams to deliver the finding of the complaint investigation for the above allegations. LPA Smith conducted a safety inspection of the STRTP on October 26, 2021 at 9:40 a.m. and no immediate deficiencies were observed. The above allegations involved clients (C1, C2, C3, C4, C5, C6, C7). During the course of investigating the allegation, LPA Smith conducted confidential interviews with clients (C2, C4, C5) and staff (S1, S2, S3, S4, S5 and S6). Client 1 (C1), Client 3 (C3), and Client 6 (C6) refused to be interviewed. LPA attempted to interview C7, however, C7 no longer resides at the facility and current whereabouts are unknown at this time. LPA reviewed reports and the records for the STRTP, staff, and clients. On October 18, 2021, a complaint was received that facility staff did not seek medical attention for minor 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: 5 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: ETTIE LEE HOME-FONTANA HOMEFACILITY NUMBER: VISIT DATE: 12/28/2021

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:


raw_content:
Narrative:
during interviews. Confidential interviews denied allegations that staff have ever hit, mistreated, denied food or ever forced any client to eat food against their religious beliefs. According to confidential information staff always accommodate or offer substitutions whenever a client does not want to or prefers to eat something else than what is being offered. Confidential interviews also denied that any staff have ever come to work impaired or inappropriately touched or crossed personal boundaries with any of the clients, and that it is sometimes the clients who have to be redirected after invading staff's personal space. According to confidential interviews, staff always follow all COVID 19 safety protocols and have never offered or provided drugs or alcohol to any of the clients in care. While other confidential information received by Licensing Office stated that these allegations had occurred. There were no other known witnessed to these allegations. Based on confidential interviews, the allegations that facility staff come to work impaired, force clients to eat food against religious preferences, that staff hit, inappropriately touch, threaten and deny youth food, encourage youth to fight, do not treat youth with dignity and respect, do not follow COVID 19 safety protocols, do not provide a safe environment for youth in care, as well as that youth have access to drugs and alcohol and that staff supply youth with drugs and alcohol, may have occurred, however is not supported or proven by evidence. Therefore, the above allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided.

Investigation Findings:
13Licensing Program Analyst (LPA), Daniel Mena met with Administrator, Patrick Williams to issue the findings for the above stated allegations. An investigation was conducted by LPAs Sarah Smith and Daniel Mena regarding allegations. LPA Smith conducted an investigation at the Short-Term Residential Therapeutic Program (STRTP) on January 31, 2022 at 1:35pm and on June 06, 2022 at 12:30pm. No immediate hazards noted. LPAs Smith and Mena interviewed Six Staff (S1, S2, S3, S4. S5 & S6), and five clients (C1, C2, C3, C4 & C5), as well as reviewed client and facility records. Community Care Licensing received information on January 25, 2022 alleging that facility staff come to work impaired, force clients to eat food against religious preferences, that staff hit, inappropriately touch, threaten and deny youth food, encourage youth to fight, do not treat youth with dignity and respect, do not follow COVID 19 safety protocols, as well as do not provide a safe environment for youth in care. Allegation also claimed that youth have access to drugs and alcohol and that staff supply youth with drugs and alcohol. Information obtained in confidential interviews did not corroborate the allegations with a preponderance of evidence. LPAs Smith and Mena obtained conflicting information UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Daniel Mena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 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: ETTIE LEE HOME-FONTANA HOMEFACILITY NUMBER: VISIT DATE: 11/04/2022

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

met_with: Patrick Williams


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews, record review, and LPA observations provided consistent accounts of the electrical system being repaired due to on-going issues. Record review revealed the facility had an estimate provided on May 22, 2025, to make repairs to the electrical system. Based on confidential interviews, observations, and record review the allegation alleging facility's electrical system is in disrepair is substantiated. The complaint allegation is valid because the preponderance of evidence standard has been met. Facility is cited for violation of California Code of Regulation (CCR) 80087(a) BUILDINGS AND GROUNDS. The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. A copy of the report was discussed and provided along with appeal rights to Administrator Patrick Williams.

Investigation Findings:
13On July 16, 2025, at 09:17AM Licensing Program Analysts (LPA) Raina Perez-Diaz, met with Ettie Lee - Fontana Home Short Term Residential Therapeutic Program (STRTP), Administrator Patrick Williams, to deliver the finding for the above stated allegation. A Health and Safety inspection of the facility was conducted on June 20, 2025, and LPA observation revealed a hazard of the electrical system being exposed which was actively being worked on at the time of inspection. The investigation was conducted by LPA's Jason Dalton and Raina Perez-Diaz and included interviews with five foster children [Child #1 (C1) - Child #5 (C5)], four staff [Staff #1 (S1)- Staff #4 (S4)], and one county social worker (CSW1). In addition, county records, and facility records were reviewed. On June 17, 2025, Community Care Licensing (CCL) received an allegation alleging the facility electrical system is in disrepair. Specifically, it was reported the electricity in the facility had been intermittent for two to three weeks causing the staff to have to reset it. ***CONTINUED ON LIC-9099-C*** SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Nicole Strickland LICENSING EVALUATOR NAME: Raina Perez-Diaz 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 61-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: ETTIE LEE HOME-FONTANA HOMEFACILITY NUMBER: VISIT DATE: 07/16/2025

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

met_with: Administrator Patrick Williams


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
A second allegation alleging facility staff did not receive training on assisting minor with self-administration of insulin. Confidential interviews provided consistent statements of not being trained on assisting minor with self-administration of insulin. Confidential interviews reported that medication training has been provided however the training did not include this type of medication and what to look for and how to verify correct dose is provided. Based on confidential interviews and record review the allegations alleging lack of supervision resulted in minor self-administering incorrect dose of medication and staff did not receive training on assisting minor with self-administration of insulin are substantiated. The complaint allegations are valid because the preponderance of evidence standard has been met. Facility is cited for violation of Interim Licensing Standards (ILS) standard PERSONAL RIGHTS (c)(1) To live in a safe, healthy, and comfortable home where they are treated with respect... and California Code of Regulations (CCR) regulation RESPONSIBILITY FOR PROVIDING CARE AND SUPERVISION (a) the licensee shall provide care and supervision as necessary to meet the client's needs. A Copy of this report, LIC 811 and Appeals Rights was provided to Administrator Patrick Williams.

Investigation Findings:
13On August 27, 2025, Licensing Program Analyst (LPA) Jacob Ortega met with Administrator Patrick Williams ETTIE LEE HOME-FONTANA HOME, to deliver the finding for the above allegations. A health and safety inspection was completed on March 5, 2025, and no immediate health and safety hazards were observed. The investigation was conducted by LPA Jason Dalton and included interviews with one client (C1) and four staff (S1-S4). Additionally, county records and facility records were reviewed. On March 4, 2025, Community Care Licensing (CCL) received an allegation alleging lack of supervision resulted in minor self-administering incorrect dose of medication. Specifically, it was reported on or about 3/1/2025, Client #1 (C1) self-administered an incorrect dosage of medication after being provided with the medication from staff. Confidential interviews provided consistent statements that while staff were present in the room at the time, staff did not verify the dosage prior to C1 self-administering the medication. CONTINUED ON C PAGE*** SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Nicole Strickland LICENSING EVALUATOR NAME: Jacob Ortega LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 61-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: ETTIE LEE HOME-FONTANA HOMEFACILITY NUMBER: VISIT DATE: 08/27/2025


summary: Facility Evaluation

raw_content:
Narrative:
On June 11, 2021 at 8: AM, Licensing Program Analysts (LPAs) Jazmond Harris and Babatunde Aborchie conducted an Annual Required Inspection and met with Facility Manager, Leilani Stevenson. The facility converted from a Group Home to STRTP (Short Term Therapeutic Program) on July 31, 2018. LPAs began a physical plant inspection at 9: AM 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 and games were observed for client'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 staff office. Chemicals/poisons and sharp objects are locked and stored in the staff office. First Aid Kits are also stored in the staff office and are complete. Licensee has provisions for contraceptives to be held individually 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 deemed safe. Facility has a pool which is appropriately fenced and secured with a wrought iron fence. The enclosure was measured to be over 5 feet tall, with a self-latching gate that swings outward. Per Facility Manager, no firearms or weapons are allowed in the facility. Facility appears to be meeting the terms and conditions of their license. Administrator, Patrick Williams is present at the facility a minimum of 20 hours a week, as verified by staff schedule and interviews. Appropriate staff/client ratios were verified during this inspection. The facility employs 5 facility managers, 10 direct care staff, a case manager, and a therapist. Licensee has obtained National Accreditation, The Accreditation is valid through February 29, 2024. Annual Fees are current. Licensee has mental health approval from July 25, 2020 until July 25, 2021. LPAs reviewed five personnel files to ensure they contained all required documentation per Title Regulations. Personnel Files are maintained off-site in a locked cabinet in staff corporate office in Baldwin Park, but documents were available for review. CPR/First Aid Certificates were observed and were valid. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. A file review of five of eight clients' (See Confidential Names List (LIC 811) dated June 11, 2021) records were also completed. No deficiencies were found during this inspection. LPAs interviewed one staff and two clients. Clients interviewed deemed that their needs were being met and they feel safe and secure in the facility. Staff and clients have no issues or concerns regarding the facility. Based upon the inspection of facility records and interviews with staff and clients, the Licensee appears to be meeting CFT and Core Services/Supports requirements. An exit interview was conducted, a copy of this report was discussed and will be provided to the facility.

met_with: Facility Manager-Leilani Stevenson


summary: Facility Evaluation

raw_content:
Narrative:
On April 4, 2023, at 09: AM, Licensing Program Analyst (LPA) Sarah Lo conducted an unannounced Annual Inspection and met with Angie Custodio, Facility Manager. The facility converted from a Group Home to STRTP (Short Term Residential Therapeutic Program) on July 31, 2018. LPA began a physical plant inspection at 09: AM 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, pool table, basketball court, swimming pool and games were observed for client'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 staff office. Chemicals/poisons and sharp objects are locked and stored in the staff office and staff restroom. First Aid Kits are also stored in the staff office and are complete. Licensee has provisions for contraceptives to be held individually 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 deemed safe and measured at 106.7, 105.7- and 105.3-degrees Fahrenheit. Facility has a pool which is appropriately fenced and secured with a wrought iron fence. The enclosure was measured to be over 5 feet tall, with a self-latching gate that swings outward. Per Facility Manager, no firearms or weapons are allowed in the facility. Facility appears to be meeting the terms and conditions of their license. Continued on LIC 809-c Administrator, Patrick 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. The facility employs 5 facility managers, 7 direct care staff, and a therapist. Licensee has obtained National Accreditation, The Accreditation is valid through February 29, 2024. Annual Fees are current. Licensee has mental health approval from July 25, 2022 until July 25, 2023. LPA reviewed five personnel files to ensure they contained all required documentation per Title Regulations. Personnel files are maintained off-site in a locked cabinet in staff corporate office in Baldwin Park, but documents were available for review. CPR/First Aid Certificates were observed and were valid. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. No deficiencies were found during this inspection. LPA reviewed five client files to ensure they contained all required documentation per Title Regulations. Client files are maintained in a locked cabinet inside staff office (See Confidential Names List (LIC 811) dated April 4, 2023) were also completed. Per review, four out of five client file was missing signed copies of the facility's policy and procedures regarding removal/transfer, discipline, and complaint. Per ILS 87070 (c) If it is determined that the facility can provide the services necessary to meet the child's needs, the following additional information shall be maintained in the child's record: (2) Signed copies of the facility's policies and procedures regarding the child's removal and/or transfer; discipline; and complaints. LPA interviewed two staffs and one client, three clients were in the facility at the time, however, one of sleeping and the other was in therapy session. The client interviewed deemed that their needs were being met and they feel safe and secure in the facility. Staffs and client have no issues or concerns regarding the facility. Based upon the inspection of facility records and interviews with staff and clients, the Licensee appears to be meeting CFT and Core Services/Supports requirements. An exit interview was conducted, a copy of this report was discussed and will be provided to Facility Manager, Angie Custodio.

met_with: Angie Custodio, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On May 20 2025, Licensing Program Analyst (LPA) Jacob Ortega and Licensing Program Manager (LPM) Nicole Strickland arrived unannounced tp Ettie Lee Home-Fontana Home for the purpose of conducting a case management other and met with Patrick Williams, STRTP Administrator . During the inspection LPA and LPM conducted an interview with Patrick Williams and collected LIC 500 staff roster. A copy of this report was given to Patrick Williams.


summary: Facility Evaluation

raw_content:
Narrative:
On May 05, 2026, at 1:40PM, Licensing Program Analyst (LPA) Daniel Mena met with Ettie Lee Facility Director, Patrick Williams regarding a case management inspection. The purpose of the inspection is to follow-up on an incident which was said to have occurred on April 18, 2026 and which was reported to Licensing Office on April 23, 2026. While at the facility LPA conducted staff and client interviews. A copy of this report was provided to Administrator.


facility_name: ETTIE LEE HOMES-DIAMOND L. RANCH

raw_content:
Narrative:
On August 22, 2022, Community Care Licensing received a complaint alleging that the facility does not meet minors' dietary needs. More specifically, staff lock the pantry and do not provide bread or fruit to C1 after 8: PM. LPA obtained conflicting statements throughout the investigation. Confidential interviews revealed that the staff prepares three meals per day and snacks between each meal. Confidential interviews revealed that the pantry closes at 8: PM and the bread is locked, however, the clients are provided a couple of options; they can have the left-over food from that day or they can make a sandwich and the staff will provide the clients with the ingredients. Other confidential interviews revealed that the left-over food cooked by staff was left out and exposed to flies therefore some clients refused to eat the food. Confidential interviews revealed that the clients have complained about only having sandwiches for a late-night snack and that C1 wants special food and if C1 did not get what C1 wanted C1 ended up breaking into the pantry at the facility. Based on confidential interviews, the allegation that the facility is not meeting minors' dietary needs, may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated at this time. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Facility Manager, Sydney Casillas On August 22, 2022, Community Care Licensing received a complaint alleging that staff speaks inappropriately to minors. Confidential interviews stated that no staff member at the STRTP has made any threats of killing a client. Confidential interviews did, however, admit that there was an incident that occurred involving S4 and Client 4 (C4). Confidential interviews further stated that S4 called "C White trash" and words were exchange between the staff member and C4. Confidential interviews also stated that the STRTP has a zero tolerance for such behaviors and have acted on those staff members behaviors. Other confidential interviews reported not witnessing staff members being inappropriate to clients. During record review LPA Urena found that the incident involving C4, and a S4 was documented by the STRTP. The documents that were collected are dated July 25, 2022, and July 26, 2022. All documents indicate that S4 did engage and exhibited inappropriate behaviors which resulted in S4 calling C4 "White trash". Based on confidential interviews and file reviews, the preponderance of evidence standard has been met, and the allegation that S4 speaks inappropriately to C4 is supported and proven by evidence. The facility is cited for violation of Short-Term Residential Treatment Facility (STRTP) Interim Licensing Standards Section 87072(c)(10) PERSONAL RIGHTS. Exit interview was conducted and a copy of this report along with the appeal rights was provided to Facility Manager, Sydney Casillas

Investigation Findings:
13On November 10, 2022, at 12: PM, Licensing Program Analyst (LPA) Cynthia Urena met with Ettie Lee Diamond L. Ranch Short Term Residential Therapeutic Program (STRTP) Facility Manager Sydney, Casillas to deliver the investigative finding for the above stated allegation. On August 29, 2022, at 8: A.M., Licensing Program Analyst (LPA) Cynthia Urena initiated the investigation at the STRTP. LPA Urena conducted a Health and Safety inspection, and no immediate deficiencies were observed. Additionally, LPA Urena interviewed three staff (S1 - S3) and 3 clients (C1-C3). At 11: A.M., LPA Urena conducted a collateral interview, and on November 9, 2022, LPA Urena interviewed a County Social Worker (CSW). LPA Urena attempted to conduct three additional interviews however Client 4 (C4) refused an interview, Client 6 (C6) could not be located for an interview, and Staff 4(S4) was terminated from employment, and could not be reached for an interview. 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 STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE This is an official report of an unannounced visit/investigation of a complaint received in our office on 08/22/2022 and conducted by Evaluator Cynthia Urena COMPLAINT CONTROL NUMBER: 19-CR- FACILITY NAME:ETTIE LEE HOMES-DIAMOND L. RANCHFACILITY NUMBER: ADMINISTRATOR:DOWNEY, CLAYTONFACILITY TYPE: ADDRESS: SPRUCETELEPHONE: (909) 877- CITY:BLOOMINGTONSTATE: CAZIP CODE: CAPACITY:9CENSUS: 8DATE: 11/10/ UNANNOUNCEDTIME BEGAN: 12: PM MET WITH:Facility Manager, Sydney CasillasTIME COMPLETED:01: PM 9Facility does not meet minors' dietary needs INVESTIGATION FINDINGS: 13On November 10, 2022, at 12: PM, Licensing Program Analyst (LPA) Cynthia Urena met with Ettie Lee L. Diamond Ranch Short Term Residential Therapeutic Program (STRTP) Facility Manager, Sydney Casillas, to deliver the investigative finding for the above-stated allegation. On August 29, 2022, at 8: AM, Licensing Program Analyst (LPA) Cynthia Urena initiated the investigation at the STRTP. LPA Urena conducted a Health and Safety inspection, and no immediate deficiencies were observed. Additionally, LPA Urena interviewed three staff (S1 - S3) and 3 clients (C1-C3). LPA Urena attempted to conduct two additional interviews however C4 refused an interview, and C6 could not be located for an interview. At 11: AM, LPA Urena conducted a collateral interview, and on November 9, 2022, LPA Urena interviewed a County Social Worker (CSW). 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: 3 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 Riverside, CA Facility Name: Ettie Lee Homes-diamond L. RANCHFACILITY NUMBER: VISIT DATE: 11/10/2022

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:

met_with: Facility Manager, Sydney Casillas


raw_content:
Narrative:
Based on inconsistent confidential interviews, the allegation that S4 threatened C1 while in care may have occurred, however, is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report along with appeal rights to given to Ettie Lee Homes Diamond L Ranch Short Term Residential Therapeutic Program (STRTP), Facility Manager, Sydney Vahle.

Investigation Findings:
13On 08/01/2024, at 12: PM, Licensing Program Analyst (LPA) Sarah Lo met with Facility Manager, Sydney Vahle, to deliver the finding for the above complaint allegation at Ettie Lee Homes Diamond L Ranch Short Term Residential Therapeutic Program (STRTP). On 03/07/24, LPA inspected the facility's physical plant, and no immediate health and safety hazards were observed. The investigation included interviews with five staff members (S1, S2, S3, S4, S5), eight County Social Workers and five clients (C1, C2, C7, C8, C9), clients (C3, C4, C5, C6) refused to be interviewed. Clients' Needs and Services Plans and case notes were reviewed. On March 5, 2024, Community Care Licensing received an allegation that staff (S4) threatened minor (C1) while in care. During the investigation, there was no corroborating evidence to support the above allegation. Although the Department received information that S4 had made threatening statement to FC1, confidential interviews could not provide consistent statements that could confirm that C1's personal rights were violated. (continued on LIC 9099c) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Sarah Lo 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 Riverside, CA Facility Name: Ettie Lee Homes-diamond L. RANCHFACILITY NUMBER: VISIT DATE: 08/01/2024

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

met_with: Sydney Vahle, Facility Manager