summary: Facility Evaluation

raw_content:
Narrative:
On August 18, 2021 at 10: AM, Licensing Program Analysts (LPA) Cindy Hamilton conducted an unannounced SB Psychotropic Medication Inspection. During the inspection, LPA Hamilton met with Anne Ford Director and Maria Alonso Facility Manager and inspected the facility inside and out. LPA reviewed 2 client psychotropic records at 10: AM. LPA reviewed three staff personnel files at the facility at 1: PM. LPA began three staff interviews at 10: AM LPA interviewed one out of two children currently taking psychotropic medication at 12: PM. Client #1 (C1) was not present at the facility at time of inspection. LPA conducted exit interview with Anne Fordr at 2: PM. LPA provided the Summary Report and Appeal Rights to Anne Ford upon completion.

met_with: Anne Ford, Director


state: CA

facility_name: CENTER FOR POSITIVE CHANGES 3

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews stated smoking is not permitted and C1 became upset due to knowing staff would be reporting the incident. Confidential interviews stated C1 and C2 exchanged words while at the facility; C1 and C2 had a physical altercation; staff intervened to separate clients; law enforcement was contacted and both clients were evaluated by urgent care before returning to the facility. Confidential interviews stated staff followed the emergency intervention plan however C1 and C2 made contact with each other before staff was able to separate them. Confidential interviews did not reveal where C1 obtained the smoking device or cigar however it was reported C1 was observed smoking outside of the facility. Confidential interviews stated staff followed the emergency intervention procedures however, it was reported that staff could have done more to maintain clients' safety and supervision. Based on confidential interviews, although the allegations that staff provided C1 with a cigar and staff did not follow the emergency intervention plan to prevent a physical altercation, may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this signed report was provided to Facility Manager Maria Alonso.

Investigation Findings:
13On 11/18/2022 at 10:00 a.m., Licensing Program Analyst (LPA) Marisol Lopez arrived at the facility unannounced and met with Facility Manager Maria Alonso, of Center for Positive Changes 3 to discuss the investigative findings for the allegations noted above. On February 4, 2022, at 10:00 a.m., Licensing Program Analyst (LPA) Marisol Lopez conducted an unannounced complaint investigation at the above facility and met with Program Director (P1) Anne Ford. LPA conducted a safety inspection, and no deficiencies were observed at that time. The investigation consisted of confidential interviews with one facility administrator, two facility staff, one of two Clients (C1-C2), one service worker and review of incident reports. On 02/22/2022, the Department received an allegation that staff provided C1 with a cigar and staff did not follow the emergency intervention plan to prevent a physical altercation. Confidential interviews stated C1 was being picked up from a self-pass when C1 was observed with a smoking device however C1 discarded the smoking device when C1 observed staff arriving. (see continuation form LIC 9099-C dated 11/18/2022) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Marisol Lopez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, METROPOLITAN DR. # FACILITY NAME: CENTER FOR POSITIVE CHANGES 3FACILITY NUMBER: VISIT DATE: 11/18/2022

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

report_type: Complaint Investigation

met_with: Facility Manager Maria Alonso

complaint_status: unsubstantiated


raw_content:
Narrative:
Confidential interviews stated the facility follows the supervision plan and maintains active supervision at all times however clients personal rights are respected. Based on confidential interviews, the allegations that client #1 (C1) has access to marijuana while in care may have occurred, however are not supported or proven by evidence. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this signed report was provided to Program Representative Maria Alonso

Investigation Findings:
13On 03/06/2023, at 11:45 a.m. Licensing Program Analyst (LPA) Marisol Lopez arrived at the facility unannounced and met with Program Representative Maria Alonso, of Center for Positive Changes 3 to discuss the investigative findings for the allegation noted above. On April 26, 2022 at 1:10 p.m., LPA conducted an initial complaint investigation and met with Program Administrator Anne Ford. LPA conducted a safety inspection and no deficiencies were observed at that time. The investigation consisted of confidential interviews with one facility administrator, four facility staff (S1- S4), one service worker, two of three clients (C1-C3) involved and reviewed incident reports. On 04/20/2022, the Department received an allegation that client #1 (C1) has access to marijuana. It was reported C1 was transported by ambulance to the hospital, due to C1 feeling weird after smoking a vape pen and no additional details were known. Confidential interviews denied that lack of supervision resulted in C1 having access to contraband however it was reported residents smoked a vape pen without staff being aware by sneaking it into the facility. (see continuation form LIC9099C dated 03/06/23) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Marisol Lopez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, METROPOLITAN DR. # FACILITY NAME: CENTER FOR POSITIVE CHANGES 3FACILITY NUMBER: VISIT DATE: 03/06/2023

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

met_with: Maria Alonso


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
...CONTINUED Confidential interviews and a review of C1's progress notes indicate that C1 would refuse treatment programs regularly and was discharged for not participating. Confidential interviews indicate that staff took C1 to their treatment programs in accordance with their plan. Confidential interviews indicate that staff take clients to the mall during "self-passes," and that C1 was seen stealing during these outings. Confidential interviews indicate that although staff were aware of C1 stealing and selling the stolen goods, staff did not encourage C1 to steal, and that C1 lost privileges for stealing. Confidential interviews indicate that clients residing at the facility can describe aspects of their Needs and Services Plan which they helped develop, and that staff follow these plans. A confidential interview disclosed that S7 was fired shortly after C1 was discharged from the facility due to "possible" involvement in C1's stealing. Conflicting confidential interviews and review of staff write-ups indicate that S7 was fired for poor boundaries with clients, and that S7 was not named as being involved in the above allegations. Based on confidential interviews and records reviewed, the allegations that that staff (S1-S4) did not ensure minor (C1) was provided access to treatment centers, and that Staff (S1-S4) did not ensure needs and services plan was followed for minor (C1) in care are unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted, and a signed copy of this report and appeal rights were provided to Maria Alonso, Facility Manager.

Investigation Findings:
13On July 11, 2024 at 10: AM, Licensing Program Analyst (LPA) Jacob Salem met with Center for Positive Changes # Maria Alonso, Facility Manager to deliver the findings for the above-stated allegations. LPA Salem initiated a complaint inspection at the facility on 2/12/2024 at 4: PM and no immediate deficiencies were observed. During the investigation, LPA Salem interviewed Clients (C1-C5), Staff (S1-S7), and a Probation Officer. LPA Salem obtained and reviewed pertinent records. On February 06, 2024, Community Care Licensing (CCL) received an allegation that staff (S1-S4) did not ensure minor (C1) was provided access to treatment centers, and that Staff (S1-S4) did not ensure needs and services plan was followed for minor (C1) in care. Confidential interviews disclosed that staff transported C1 to shopping malls and stores instead of C1's schedules treatment programs, and that staff encouraged C1 and C2 to steal items from stores. A conflicting confidential interview with C2 indicates that staff did not encourage or assist C1 with stealing. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Center for Positive Changes 3facility Number: Visit Date: 07/11/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...CONTINUED Confidential interviews and a review of C1's progress notes indicate that C1 would refuse treatment programs regularly and was discharged for not participating. Confidential interviews indicate that staff took C1 to their treatment programs in accordance with their plan. Confidential interviews indicate that staff take clients to the mall during "self-passes," and that C1 was seen stealing during these outings. Confidential interviews indicate that although staff were aware of C1 stealing and selling the stolen goods, staff did not encourage C1 to steal, and that C1 lost privileges for stealing. Confidential interviews indicate that clients residing at the facility can describe aspects of their Needs and Services Plan which they helped develop, and that staff follow these plans. A confidential interview disclosed that S7 was fired shortly after C1 was discharged from the facility due to "possible" involvement in C1's stealing. Conflicting confidential interviews and review of staff write-ups indicate that S7 was fired for poor boundaries with clients, and that S7 was not named as being involved in the above allegations. Based on confidential interviews and records reviewed, the allegations that that staff (S1-S4) did not ensure minor (C1) was provided access to treatment centers, and that Staff (S1-S4) did not ensure needs and services plan was followed for minor (C1) in care are unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted, and a signed copy of this report and appeal rights were provided to Maria Alonso, Facility Manager. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of 2

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

met_with: Maria Alonso, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On December 10, 2021 at 9: AM, Licensing Program Analyst (LPA) Marisol Lopez conduted a pre-licensing inspection for a change in relocation from Vista Del Monte Way, El Cajon Ca 92020 to the above facility. LPA met with Anne Ford, Residential Services Director (D1) and Deanna Mellos, Director (D2). LPA toured the facility inside and outside with D1 and D2. No one currently resides in the home. The facility will serve six females from 13-17 years old and non-minor dependents. The facility has four bedrooms, staff office, living room, kitchen/dining room, laundry room in garage, two client bathrooms, and a separate therapist office with staff bathroom and kitchen.. The bedrooms are set up as follows: Bedroom #1- One twin bed, one dresser and closet space for one client.. Bedroom #2- Two twin beds with two dressers and closet space for two clients. Bedroom #3- Two twin beds with two dressers, closet space for two clients and an attached bathroom.. Bedroom #4- One twin bed with one dresser and closet space for one client. Bedroom #1, #2 and #4 will be sharing one bathroom with double sinks. Smoke detectors and carbon monoxide detectors are properly working throughout the facility. Toxins will be locked in the cleaning supply closet. The garage to the laundry area will be maintained locked. The First Aid Kit, medications, medication logs and knives will be maintained locked in a cabinet in the staff office. The client files and staff files will be maintained locked in staff office. There is plenty of storage room, three desks, couch and file cabinets in staff office. The kitchen will be stocked with three days perishable and seven days non-perishable foods. Hot water temperature is reading at 115 degrees F. (See Continuation form LIC809-C dated 12/10/2021) There was an ample amount of recreational and leisure supplies such as books, games and television available for client use. Emergency exits were free from obstruction. The yard contains an outdoor deck area, chairs, a grill, jacuzzi and swimming pool. The pool is surrounded with an appropriate fence that is a 5ft wrought iron fence with a key locked gate that is self latching. The jacuzzi has a locked cover with crossed double locks and is not accessible. Emergency exits were free from obstruction. The home will operate within the capacity and limitation of the license. The home is clean, safe sanitary and in good repair. All staff that work at the facility will have Department of Justice and Child Abuse Clearance Index clearances. . The following required posted items were observed and accessible to clients: Grievance Procedures, Personal Rights, Ombudsman, Visitation policies, and current menu. The facility has demonstrated compliance with Title 22, Division 6 of the California Code of Regulation. An exit interview was conducted with the licensee and a copy of this report was given to Anne Ford, Residential Services Director (D1) and Deanna Mellos, Director (D2). .

report_type: Facility Evaluation

visit_type: Prelicensing

met_with: Anne Ford


summary: Facility Evaluation

raw_content:
Narrative:
On July 20, 2022 at 10: AM, Licensing Program Analyst (LPA) Marisol Lopez conducted a post-licensing inspection for a change in relocation from Vista Del Monte Way, El Cajon Ca 92020 to the above facility. LPA met with Marla Cooper, Program Administrator (P1) and toured the facility inside and outside. The facility serves six females ages 13-17 years old and non-minor dependents. There is a current census of 5 clients however, clients were not present during the inspection. The facility has four bedrooms, staff office, living room, kitchen/dining room, laundry room in garage, two client bathrooms, and a separate therapist office with staff bathroom and kitchen. The bedrooms are set up as follows: Bedroom #1- One twin bed, one dresser and closet space for one client. Bedroom #2- Two twin beds with two dressers and closet space for two clients. Bedroom #3- Two twin beds with two dressers, closet space for two clients and an attached bathroom. Bedroom #4- One twin bed with one dresser and closet space for one client. Bedroom #1, #2 and #4 share one bathroom with double sinks. Smoke detectors and carbon monoxide detectors are properly working throughout the facility. Toxins are locked in the cleaning supply closet. The garage to the laundry area is maintained locked. The First Aid Kit, medications, medication logs and knives will are maintained locked in a cabinet in the staff office. The client files and staff files will be maintained locked in staff office and readily available upon request. There is plenty of storage room, three desks, couch and file cabinets in staff office. The kitchen is stocked with more than three days perishable and seven days non-perishable foods. Hot water temperature is reading at 117 degrees F. There is an ample amount of recreational and leisure supplies such as books, games and television available for client use. Emergency exits are free from obstruction. The yard contains an outdoor deck area, chairs, a grill, jacuzzi and swimming pool. The pool is surrounded with an appropriate fence that is a 5ft wrought iron fence with a key locked gate that is self latching. The jacuzzi has a locked cover with crossed double locks and is not accessible. Emergency exits are free from obstructions or hazards. The home operates within the capacity and limitation of the license. The home is clean, safe sanitary and in good repair. All staff that work at the facility will have Department of Justice and Child Abuse Clearance Index clearances. The following required posted items were observed and accessible to clients: Grievance Procedures, Personal Rights, Ombudsman, Visitation policies, and current menu. LPA reviewed five of five client files and ten of ten staff files (see confidential name list, LIC811, dated 07/20/2022). All client files had the required forms per regulations requirements. LPA conducted 2 of 10 staff interviews and 0 of 10 client interviews. Based on record review, the licensee did not comply as 10 out of 10 staff files (S1-S10) did not have record of completing a minimum of 40 hours of annual training; 10 out of 10 staff files (S1-S10) did not have documentation of successful completion of training maintained in the personnel record for each direct care staff; and 10 out of 10 staff files (S1-S10) did not implement a written plan for the supervision, evaluation, and training of all direct care staff which poses a potential health, safety or personal rights risk to persons in care. The facility is being issued a citation in accordance with the Title 22, ILS sections 87065.1(c), 87065.1(d)(5) and 87065.1(e)(1). See LIC809-D dated 07/20/22 for the cited deficiency. An exit interview was conducted, and this report, appeal rights and LIC 811 was reviewed with Program Administrator Marla Cooper and a copy of this report was provided

met_with: Marla Cooper


summary: Facility Evaluation

raw_content:
Narrative:
On December 20, 2022 at 09: AM, Licensing Program Analyst (LPA) Lucero Jauregui conducted announced annual facility inspection. LPA met with Anne Ford, Director and toured the facility inside and outside. The facility serves six females ages 13-17 years old and non-minor dependents. There is a current census of 5 clients however, one client was present during the inspection. The facility has four bedrooms, staff office, living room, kitchen/dining room, laundry room in garage, two client bathrooms, and a separate therapist office with staff bathroom and kitchen. The bedrooms are set up as follows: Bedroom #1- One twin bed, one dresser and closet space for one client. Bedroom #2- Two twin beds with two dressers and closet space for two clients. Bedroom #3- Two twin beds with two dressers, closet space for two clients and an attached bathroom. Bedroom #4- One twin bed with one dresser and closet space for one client. Bedroom #1, #2 and #4 share one bathroom with double sinks. Smoke detectors and carbon monoxide detectors are properly working throughout the facility. Toxins are locked in the cleaning supply closet. The garage to the laundry area is maintained locked. The First Aid Kit, medications, medication logs and knives will be maintained locked in a cabinet in the staff office. The client files and staff files will be maintained locked in staff office and readily available upon request. There is plenty of storage room, two desks, couch and file cabinets in staff office. The kitchen is stocked with more than three days perishable and seven days non-perishable foods. Hot water temperature is reading at 117 degrees Fahrenheit. Continued... There is an ample amount of recreational and leisure supplies such as books, games and television available for client use. Emergency exits are free from obstruction. The yard contains an outdoor deck area, chairs, jacuzzi and swimming pool. The pool is surrounded with an appropriate fence that is a 5ft wrought iron fence with a key locked gate that is self latching. The jacuzzi has a locked cover with crossed double locks and is not accessible. Emergency exits are free from obstructions or hazards. The home operates within the capacity and limitation of the license. The home is clean, safe sanitary and in good repair. All staff that work at the facility will have Department of Justice and Child Abuse Clearance Index clearances. The following required posted items were observed and accessible to clients: Grievance Procedures, Personal Rights, Ombudsman, Visitation policies, and current menu. LPA reviewed five client files and five staff files (see confidential name list, LIC811, dated 12/20/2022). All client files had the required forms per regulations requirements. A review of administrative records indicate that the facility has paid their current licensing fees. LPA conducted 2 staff interviews and one client interview. Based on the facility inspection and file reviews conducted, there are no deficiencies found at this time. A exit interview was conducted. A copy of this report was reviewed and given to Anne Ford, Director along with appeal rights and Confidential Names List (LIC 811).

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
On April 29, 2024, at 9:35 a.m., Licensing Program Analyst (LPA) Jacob Salem arrived at the above facility for the purpose of conducting an unannounced annual inspection. LPA met with Anne Ford, Residential Director and explained the purpose of the visit. LPA began the inspection by reviewing client files and medication logs for C1-C5 (see LIC Confidential Name List dated 4/29/24). Client files are kept locked in the staff office and were provided to LPA for review upon request. All five client files contained the required paperwork, including signed admission agreement, signed needs and services plans, required medical documentation, court orders for psychotropic medication, and records of cash resources and personal property. LPA also observed all required information to be recorded in each clients' medication administration records (MARs), including name of medication, day and time taken, staff initials, and name and number of prescribing physician. Lastly, a separate MARs is kept for each psychotropic medication that is approved and taken by clients. LPA then conducted two confidential staff interviews. Finally, LPA inspected the facility's physical plant. The facility is a one-story residence with a garage, wrap-around deck, and patio. Inside the residence there are four client bedrooms, two bathrooms, kitchen, staff office, and living room. There are currently six clients residing at this facility with no more than two clients sharing a bedroom. The front hallway prominently displays the facility license, client grievance procedures, and foster child bill of rights. All four bedrooms had mattresses and pillows in good condition, clean sheets and blankets, and closet or dresser space with clothing. Both bathrooms were clean and sanitary with a working shower, sink, and toilet. Toiletries and personal hygiene supplies are provided to clients. LPA observed the kitchen to be clean and sanitary. Continued... ...CONTINUED LPA observed the refrigerator, pantry, and chest freezer to contain enough food to meet the requirement for food supplies. Finally, LPA observed a menu for the week posted on the garage door in the kitchen, which consisted of three meals. LPA observed the living room to be clean and contain a large couch and TV. A large poster for the Foster Children Personal Rights is also posted in the living room area. The closet in the front hallway was observed to be locked and contains disinfectants, detergents, and other cleaning solutions. The cabinets in the staff office were also observed to be locked and contact sharps objects and medication. The facility contains two carbon monoxide and smoke detectors, both of which were tested to be operable. The garage contains a washer and dryer machine, both of which were clean and in good condition. The backyard consists of a patio, pool with locked fence, and large side yard. LPA observed no safety hazards in the outdoor area. Due to time constraints, the annual is being extended to conduct an inspection of the staff files and client interviews. Based on observations made during the inspection, there were no deficiencies cited at this time. An exit interview was conducted with Anne Ford, Residential Director and a signed copy of this report was provided.

met_with: Anne Ford, Residential Director


summary: Facility Evaluation

raw_content:
Narrative:
On May 3, 2024 at 9: AM, Licensing Program Analyst (LPA) Jacob Salem arrived to the facility and met with Anne Ford, Residential Director. The purpose of this Case Management inspection is to conduct an annual continuation from 4/29/2024. LPA reviewed five staff files (S1-S5) at the facility's corporate office. The staff files have the required background information and health screenings, criminal record clearances, staff qualifications, and training requirements. During the file review, LPA observed the facility administrator (S1) to not be currently certified. LPA reviewed the emergency intervention plan and disaster preparedness plan at the facility, both of which contained all of the required information. LPA inspected the facility car used to transport clients, which is in safe and operating condition. Finally, LPA tested the water temperature in the two client bathrooms and measured the first bathroom's sink to run at 109.2 degrees F, and the second to be 108 degrees F. Based on LPA's observation, the facility is cited for violation of Interim Licensing Standards, regulation 87064(b) Administrator Qualifications and Duties. An exit interview was conducted with Anne Ford, Residential Director. Due to printer malfunction a signed copy of this report, LIC 811, and appeal rights were emailed to Anne Ford.

visit_type: Case Management


facility_name: CENTER FOR POSITIVE CHANGES 5

raw_content:
Narrative:
Confidential interviews did not provide consistent statements whether staff did not transport youth in care to school, staff discriminated against youth in care, the facility refrigerator in disrepair, and the facility bathroom in disrepair. Confidential interviews and record review for the incident did not provide a preponderance of evidence to prove or disprove the allegation staff did not transport youth in care to school, staff discriminated against youth in care, facility refrigerator in disrepair, and facility bathroom in disrepair. Therefore, the allegation is unsubstantiated. LPA Jauregui conducted an exit interview and provided a copy of this report along with appeal rights to Adelicia Zenon, Facility Manager.

Investigation Findings:
13On May 12, 2023, at 09: AM, Licensing Program Analyst (LPA) Lucero Jauregui conducted a complaint inspection at Center for Positive Changes 5 and met with Adelicia Zenon, Facility Manager. The purpose of the inspection was to deliver the findings for the above complaint allegation. LPA Marisol Lopez conducted an inspection of the facility on November 9, 2022, and no deficiencies were noted. During the investigation, LPA Lopez requested incident report, current client roster, staff contact information, and proof of purchase of new refrigerator. During the investigation LPA Jauregui conducted record review, four staff interviews (S1-S4), and three client interviews (C1, C3, C5). LPA attempted to interview C2 and C4. However, after numerous attempts LPA was unsuccessful. On November 2, 2022, the Department received a complaint report, with allegations that staff did not transport youth in care to school, staff discriminated against youth in care, facility refrigerator in disrepair, and facility bathroom in disrepair. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SO. Cal Sc/res, Metropolitan Dr. # FACILITY NAME: CENTER FOR POSITIVE CHANGES 5FACILITY NUMBER: VISIT DATE: 05/12/2023

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

met_with: Adelicia Zenon, Facility Manager


raw_content:
Narrative:
C1's bedroom is located within feet of the front door and when staff approached C1, C1 denied having anything. Staff then checked back in on C1 fifteen minutes later. C1 did indeed overdose on over the counter medication but it is unknown if it was due to lack of supervision. Based on confidential interviews, the allegation that facility staff did not prevent minors from having access to medication while in care due to lack of supervision may have occurred, however is not supported, or proven by evidence. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this signed report was provided to Adelicia Zenon, Facility Manager.

Investigation Findings:
13On October 10, 2023, at 9: AM, Licensing Program Analyst (LPA) Lucero Jauregui arrived at the facility unannounced and met with Adelicia Zenon, Facility Manager to discuss the investigative findings for the allegation noted above. LPA Jauregui conducted an inspection of the facility on June 6, 2023, and no deficiencies were noted. During the investigation, LPA Jauregui interviewed four staff (S1-S4), one client (C1) and obtained C1's needs and services plan, C2's needs and services plan, staff schedule with contact information for 5/24/23 , client roster, log notes and progress notes for 5/24/23. LPA was unable to interview C2 due to C2 refusing. On June 1, 2023, the department received an allegation that facility staff did not prevent minors from having access to medication while in care due to lack of supervision. Interviews indicated C1 made an Instacart account, placed an Instacart order for cough & cold HBP pills to be delivered to the facility. Interviews indicated C1 was seen to go to the front door, open the door, retrieve a black bag and go to their room. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: LUCERO JAUREGUI LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SO. Cal Sc/res, Metropolitan Dr. # FACILITY NAME: CENTER FOR POSITIVE CHANGES 5FACILITY NUMBER: VISIT DATE: 10/10/2023

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


raw_content:
Narrative:
...CONTINUED Confidential interviews disclosed that staff decided to enroll C1 in school immediately and did not disclose C1's medical needs regarding their inhaler and epi-pen during enrollment. Confidential interviews indicate that although C1 was enrolled on 12/11/2023, C1 did not begin attending classes until 01/08/2024. A confidential interview revealed that the facility supplied C1's school with the prescription medications eleven days after C1 began attending school once the facility received authorization from the doctor. The Department also received the allegation that staff (unnamed) does not ensure minor(s) (unidentified) attend school. Confidential interviews indicated that staff wakes clients up in the morning and transports clients to school unless other transportation arrangements are made. Confidential interviews and a record review of special incident reports reveal that clients in the home regularly refuse to attend school. A confidential interview indicated that although staff attempt to wake clients up in the morning, staff are not encouraging regarding school attendance. Conflicting confidential interviews indicate that staff are encouraging and make several attempts to encourage clients to wake up and attend school. Based on confidential interviews and records reviewed, the allegations that staff (unnamed) does not communicate the minor's (C1) medical needs to the minor's (C1) school and that staff (unnamed) does not ensure the minor(s) (unidentified) attend school are unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted, and a signed copy of this report and appeal rights were provided to Adelicia Zenon, Facility Manager.

Investigation Findings:
13On June 21, 2024 at 12: PM, Licensing Program Analyst (LPA) Jacob Salem met with Center for Positive Changes # Adelicia Zenon, Facility Manager to deliver the findings for the above-stated allegations. During the investigation, LPA Salem interviewed Clients (C1-C2), Staff (S1-S4), a School Nurse, and two County Social Workers. LPA Salem obtained and reviewed pertinent records. On January 09, 2024, Community Care Licensing (CCL) received an allegation that staff (unnamed) did not communicate the minor's (C1) medical needs to the minor's (C1) school. Confidential interviews and records reviewed reveal that C1 was enrolled in school by staff without providing the school with C1's prescription inhaler and epi-pen. Confidential interviews and records review reveal that C1 refused a medical appointment on 01/04/2024, resulting in the facility not obtaining authorization to provide the school with the medication. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Center for Positive Changes 5facility Number: Visit Date: 06/21/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...CONTINUED Confidential interviews disclosed that staff decided to enroll C1 in school immediately and did not disclose C1's medical needs regarding their inhaler and epi-pen during enrollment. Confidential interviews indicate that although C1 was enrolled on 12/11/2023, C1 did not begin attending classes until 01/08/2024. A confidential interview revealed that the facility supplied C1's school with the prescription medications eleven days after C1 began attending school once the facility received authorization from the doctor. The Department also received the allegation that staff (unnamed) does not ensure minor(s) (unidentified) attend school. Confidential interviews indicated that staff wakes clients up in the morning and transports clients to school unless other transportation arrangements are made. Confidential interviews and a record review of special incident reports reveal that clients in the home regularly refuse to attend school. A confidential interview indicated that although staff attempt to wake clients up in the morning, staff are not encouraging regarding school attendance. Conflicting confidential interviews indicate that staff are encouraging and make several attempts to encourage clients to wake up and attend school. Based on confidential interviews and records reviewed, the allegations that staff (unnamed) does not communicate the minor's (C1) medical needs to the minor's (C1) school and that staff (unnamed) does not ensure the minor(s) (unidentified) attend school are unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted, and a signed copy of this report and appeal rights were provided to Adelicia Zenon, Facility Manager. SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of 4

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


raw_content:
Narrative:
Confidential interviews reported that S1 called one or more minors a liar and yelled at them. Other confidential interviews reported that S1 is respectful to the minors in care and is well liked by the minors in care. Confidential interviews reported that S1 was threatening to assign one of the minors a transgender person for a roommate. Other confidential interviews reported that S1 made no such statement to any minor in care at the facility. LPAs received inconsistent information. Regarding the allegation that staff (S1) have not provided a minor (C1) with personal belongings; it was reported that after C1 they were discharged from the facility and the facility did not send C1's clothing to C1's new placement. It was further reported that S1 informed C1's family that these items wouldn't be shipped until the facility received shipping costs from C1's County Representative. Confidential interviews reported that the facility did not forward/ship C1's belongings after C1 had discharged from the facility. Confidential interviews reported that C1 had approximately seven boxes of belongings and that the facility only shipped six boxes to C1. Other confidential interviews reported that after the facility sent C1 the initial six boxes of belongings, they realized after the fact that they forgot to send the seventh box which they then shipped out to C1. Based on confidential interviews and record reviews, the allegations that staff spoke inappropriately to minors and staff have not provided a minor with personal belongings may have occurred, however, there was not a preponderance of evidence to support the alleged violations. Therefore, the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report and appeal rights were explained and given to Administrator Adelicia Zenon.

Investigation Findings:
13On 7/10/25, at 10:43AM, Licensing Program Analysts Joon Choi and Cynthia Ramos (LPAs) conducted an unannounced visit at Center for Positive Changes # Short Term Residential Treatment Program (STRTP) and met with Administrator Adelicia Zenon to deliver the investigative finding for the allegation listed above. On 12/20/2024, Community Care Licensing received allegations that staff spoke inappropriately to minors and staff have not provided a minor with personal belongings. On 12/20/2024, LPA Jacob Salem arrived at the facility, conducted a health and safety inspection, and obtained pertinent documents. No immediate health and safety hazards were observed. LPA Salem interviewed clients 2 and 4 (C2, C3), staff 2 and 3 and (S2, S3) and County Social Worker (CSW). In addition, LPA Joon Choi interviewed client 1 (C1) and staff 1 (S1). In regard to the allegation that staff (S1) spoke inappropriately to minors (C1, C2, C3); it was reported that S1 spoke in a demeaning manner to C1, C2 and C3- by "calling them liars, yelling at them and telling them that they were wrong." It was further reported that S1 informed one of the minors that they would assign them a "tranny", as a roommate. CONTINUED ON THE NEXT PAGE UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Joon R Choi LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: CENTER FOR POSITIVE CHANGES 5FACILITY NUMBER: VISIT DATE: 07/10/2025

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

met_with: Adinistrator, Adelicia Zenon


raw_content:
Narrative:
reported that C1 did not provide any names of who was responsible for C1's trafficking. Confidential interviews reported that C1 admitted to being involved in CSEC activities prior to and during their placement at their current facility. Other confidential interviews reported that facility staff counseled C1 on the dangers of CSEC activities. Confidential interviews reported that the facility staff conducted their routine safety checks and room checks on clients per the facility protocol. Other confidential interviews reported that C1 was not able to be located during this investigation to obtain their testimony on the facility's supervision and care. Based on confidential interviews and record reviews, the allegation that due to lack of care and supervision, C1 was engaging in CSEC activities may have occurred, however, there was not a preponderance of evidence to support the alleged violation. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report and appeal rights were explained and given to Administrator Adelicia Zenon.

Investigation Findings:
13On 07/10/25, at 11:04AM, Licensing Program Analyst (LPAs) Joon Choi and Cynthia Ramos conducted an unannounced visit at Center for Positive Changes # Short Term Residential Treatment Program (STRTP) and met with Administrator Adelicia Zenon to deliver the investigative finding for the allegation listed above. On 10/29/2024, Community Care Licensing received an allegation that due to lack of care and supervision, minor was engaging in (commercial sexually exploited child) CSEC activities. On 11/04/2024, LPA Jacob Salem arrived at the facility, conducted a health and safety inspection, and obtained pertinent documents. No immediate health and safety hazards were observed. In addition, LPA Salem interviewed clients 2, 3 and 5 (C2, C3, C5), staff 1 and 2 (S1, S2) and County Social Worker (CSW). Client 1 (C1) was not able to be located for an interview and Client 5 (C5) declined LPA's request for an interview. In regard to the allegation that due to lack of care and supervision, minor (C1) is engaging in CSEC activities; it was reported that C1 disclosed voluntarily being involved with "human trafficking." It was further CONTINUED ON THE NEXT PAGE UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Joon R Choi LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: CENTER FOR POSITIVE CHANGES 5FACILITY NUMBER: VISIT DATE: 07/10/2025

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

met_with: Administrator, Adelicia Zenon


summary: Facility Evaluation

raw_content:
Narrative:
On 06/11/2021 at 09: A.M., Licensing Program Analyst (LPA) Marisol Lopez conducted an unannounced required annual inspection of the facility and met with Program Supervisor (P1) Augrista Belford. LPA and P1 inspected the facility inside and out. Presently there are six clients living in the home (C1, C2, C3, C4, C5, C6) (See Lic. Confidential Names dated 06/11/2021). The facility is a one-story residence with three bedrooms, two bathrooms, dining room, dining area, living room, family room, kitchen, laundry room, staff office and 2-car garage. The facility has been operating with a capacity of six females from ages 13 years old to 17 years old and non-minor dependents. The bedrooms are set up as follows: Bedroom #1, Bedroom #2 and Bedroom #3 each is used by two clients, is furnished with two twin beds, all required linen, and mattresses in good condition. There is adequate drawer and closet space for client's belongings. Bedroom are arranged so that no more than two clients share a room, and there is one client per bed. No room commonly used for other purposes is used as a bedroom. LPA observed a sufficient supply of 7-day non-perishable food for six clients and a sufficient supply of 2-day perishable food in the kitchen. LPA observed the kitchen to be clean, sanitary and in good repair. The dining room is located next to the kitchen and contains one table with four chairs, the dining area has one table with three chairs and the kitchen counter bar has three bar height chairs. The living room contains two couches and a large ottoman. The family room contains two couches, a tv cabinet with television, a game system with multiple games, as well as books and board games. The laundry room contains a washer and dryer. LPA tested the hot water temperature in clients bathroom which read 120.0 degrees Fahrenheit, which is in the acceptable range of 105 degrees and 120 degrees Fahrenheit. The two-car garage contains a second freezer for overflow foods and storage is maintained in garage. LPA observed an ample amount of recreational and leisure supplies such as books, games, art supplies and television available for client use. Emergency exits were free from obstruction. LPA inspected the outside grounds, which included the backyard. The exterior of the facility was found to be clean and well maintained. The locked staff office contained office furniture and equipment, a locked medications room with two locked file cabinets, one of which holds medications, medications logs, cleansers and cleaners, and two first aid kits, which contained all required items. The locked closet also contains office documents, client files and office supplies. Sharp knives are kept in a locked cabinet in the locked closet inside the locked staff office. The licensee stated that there are no guns on the premises. The facility's combination smoke detectors/carbon monoxide detectors located in all bedrooms and in the hallway were tested and were operable The following required posted items were observed and accessible to children: Ombudsman and Foster Youth Bill of Rights, Grievance Procedures, Personal Rights, Visitation Policies, Neighbor complaint Policy, house rules and current menu. Licensee has obtained National Accreditation through CARF and the Accreditation is valid through August 2022. LPA discussed the following with Program Supervisor: Incident reporting, including incidents related to Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. Personnel Files are maintained off-site and transported to LPA within a reasonable time. All staff who work at the facility have Department of Justice and Child Abuse Clearance index check clearances. A review of client records was also completed on this date including the Medication Administration Record (See Confidential Name List- LIC 811 dated on June 11, 2021). Personnel files were reviewed to ensure they contained all required documentation. Children and staff records are organized. Staff's CPR and First Aid card were current. Child's records contain original needs and services plan signed by the child and their authorized rep. Child's records contain authorization for emergency medical care signed by each child's authorized rep. Appropriate staff/client ratios were verified during this inspection. Based on observations made during the inspection, no deficiencies observed during today's visit. An exit interview was conducted and this report was reviewed with Program Supervisor Augrista Belford and a copy of this report was provided.

met_with: Augrista Belford


summary: Facility Evaluation

raw_content:
Narrative:
On September 17, 2022 at 11:20 am, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility for the purpose of conducting a collateral interview with one client that is currently residing at the facility. LPA met with Danikka Alarcon, Child Care Worker, and explained that the complaint investigation is not on their facility. LPA conducted one interview with one client. LPA toured the facility and the facility was in compliance with Title 22 regulations, Chapter 5, therefore no deficiencies were cited.

met_with: Danikka Alarcon, Child Care Worker


summary: Facility Evaluation

raw_content:
Narrative:
On November 29, 2022 at 2:30 pm, Licensing Program Analyst (LPA) Charmaine Linley arrived unannounced to the facility for the purpose of conducting a collateral interview with one client that is currently residing at the facility. LPA met with Denice Fortune, Facility Administrator and explained that the complaint investigation is not on their facility. LPA conducted one interview with one client. LPA toured the facility and the facility was in compliance with Title 22 regulations, Chapter 5, therefore no deficiencies were cited. Facility Administrator was reminded the facility always needs to have a Facility Manager designated when the Administrator is not at the facility, Facility Administrator arrived to the facility within twenty minutes of LPA arriving at the facility.

met_with: Denice Fortune, Facility Administrator


facility_name: CENTER FOR POSITIVE CHANGES 6

raw_content:
Narrative:
The agency has investigated the complaint allegations; facility did not provide adequate supervision that resulted in a youth being found in and out of conscious in the bathroom on February 1, 2021 and staff is not qualified to administer CPR. Adequate supervision was being conducted at Center for Positive Changes 6. C1 declined to finish her interview. However, C1 did state that staff checked on the youths at the facility often. C2 stated room checks are conducted every 15 or 10 minutes. LPA Shelton requested and received copies of all staff's CPR Cards and found them in compliance. All staff interviewed stated, they could perform CPR on an adult or youth in case of an emergency. Staff did not perform CPR when the youth was found in the bathroom. The youth was breathing on her own and CPR was not needed. 911 was called and staff remained on the phone until EMT's arrived at the facility. As a result of the investigation, the complaint is UNSUBSTANTIATED -meaning although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that alleged violation did or did not occur, therefore the allegation is unsubstantiated. No title 22 regulations were cited during today's inspection. An exit interview was conducted with Administrator, Staci Exceus. A copy of the report and appeal rights were provided to the facility.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton conducted a tele visit at the agency on May 25, 2021 and LPA spoke with Staci Exceus, Administrator to deliver findings of the investigation on the complaint allegations as stated. The initial 10-day complaint inspection was conducted by LPA Mary Shelton, at the agency on 2/12/2021 and included a review of the facility and obtaining of relevant documents: Needs and Services, a roster of all the residents, staff schedule, copies of staff CPR cards, room check log, and the daily schedule of actives. LPA Shelton interviewed the facility administrator on 4/13/2021. Additional interviews were conducted, which included C1, C2, staff and therapist between 3/22/2021 and 5/4/2021. 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: CENTER FOR POSITIVE CHANGES 6FACILITY NUMBER: VISIT DATE: 05/25/2021

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

met_with: Staci Exceus, Administrator


raw_content:
Narrative:
C1 was at the home for 25 days and continuously AWOL'd. According to Incident reports and interviews Staff would follow C1 and try to redirect C1 back to the home. These AWOL's were reported to CCL and law enforcement. LPA was unable to interview C1 and C1's whereabouts are unknown. However, C1 has stayed in contact with her CASA Worker to let her know she is alright. Based on the investigation, records reviewed and interviews conducted, the complaint findings are 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 regulations were cited during today's inspection. An exit interview was conducted with Administrator, Staci Exceus. A copy of the report and appeal rights were provided to the facility.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton conducted a visit at the agency on July 1, 2021 and LPA spoke with Nicole LaChandia, Manager to deliver findings of the investigation on the complaint allegation as stated. LPA Shelton informed the complaint investigation included a tour of the facility on 4/6/2021. The initial 10-day complaint inspection was conducted by LPA Mary Shelton, at the agency on 4/6/2021 and included a review of the facility and obtaining of relevant documents: Needs and Services, monthly treatment plan and placement history. LPA Shelton interviewed the facility administrator on 4/6/2021. Additional interviews were conducted with the social worker, CASA worker and staff between 4/6/21 and 6/30/2021. The agency has investigated the complaint allegation that staff did not adequately supervise the resident. C1 (DOB 10/8/2003) was placed at the facility on 3/11/2021 and her bed was closed on 4/5/2021. 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: CENTER FOR POSITIVE CHANGES 6FACILITY NUMBER: VISIT DATE: 07/01/2021

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

met_with: Nicole LaChandia, Manager


raw_content:
Narrative:
C1's placement date was 9/9/2020 and was discharged on 2/4/2021. C1 declined to be interview regarding this complaint on 7/9/2021. The Department has investigated the complaint allegation, that Facility staff did not provide adequate supervision. Based on documentation and interviews with C2 and staff, there was adequate supervision regarding C1. In addition, on 1/20/2021 the home where C1 was placed filed a Suspected Child Abuse Report, contacted law enforcement, and submitted an Incident Report to CCL. C1 reported to staff, after returning from being AWOL that C1 had possible been sexual assaulted at a birthday party and there were illegal substance and alcohol provided to her by a peer and that same peer had sent C1 a photo of C1 in her bra and underwear. Based on the investigation, records reviewed and interviews conducted, the complaint findings are 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. A copy of this report and appeal rights were given to the agency. No title 22 regulations were cited during today's inspection.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton conducted a visit at the agency on 7/19/2021 and LPA spoke with Staci Exceus, 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 on 4/6/2021. The initial 10-day complaint inspection was conducted by LPA Mary Shelton, at the agency on 4/19/2021 and included a review of the facility and obtaining of relevant documents: Needs and Services, monthly treatment plan and placement history. LPA Shelton interviewed the facility administrator on 4/19/2021. Additional interviews were conducted with C2, social worker and staff between 4/19/21 and 7/1/2021. 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: CENTER FOR POSITIVE CHANGES 6FACILITY NUMBER: VISIT DATE: 07/19/2021

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


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
LPA explained the allegation that the facility did not properly check C1's belongings upon return which, resulted in C1 having alcohol, syringes, and Insulin in C1's possession. Due to the surrounding circumstances, staff was not able to follow protocol. The minor was upset about returning from a home visit with C1's aunt and asked for more time to say good-bye. Staff was unaware the visit had ended and C1 returned to her room without her belongings being checked. As a result of interviews conducted with the administrator, staff, and clients the complainant, Staff did not check minors belongs upon return is SUBSTANTIATED meaning that the allegation is valid because the preponderance of the evidence standard has been met. The facility was not cited on this date as the incident appears to be an isolated incident since initially being addressed staff will now check minors' belongings upon return. The Facility has taken great measures to ensure this does not happen again. The Facility was advised that should another incident of this nature happen again, then the facility may be cited, or further action be taken. No title 22 regulations were cited during today's inspection. Exit interview conducted with Staci Exceus and documents and appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton conducted a visit on March 30, 2022, and LPA spoke with Staci Exceus, 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 on 11/30/2021. The initial 10-day complaint inspection was conducted by LPA Mary Shelton, at the agency on 11/30/2021 and included a review of the facility and obtaining of relevant documents: Needs and Services, monthly treatment plan, supervised visit log, certificate of approval and training records. Additional interviews were conducted by LPA Mary Shelton, which included Reporting Party, C1, C2, S1, S2, S3, S4,S Administrator and Social Worker between 12/9/2021 and 3/23/22. C1 is currently placed back in the home. 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: CENTER FOR POSITIVE CHANGES 6FACILITY NUMBER: VISIT DATE: 03/30/2022

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

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
The Department has investigated the complaint allegation, that staff not providing adequate supervision. Based on documentation that the Administered provided to CCL (Copies of Coan Logbook 11.28.21 to 11.29.21) outlining room checks or being conducted every 15 minutes or sooner. Clients interviewed stated they are checked on often and Staff interviewed said the protocol is to check on all clients every 15 minutes or sooner, if needed. There was adequate supervision regarding C1 and other clients in care. Based on the investigation, records reviewed, and interviews conducted, the complaint findings are 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. A copy of this report and appeal rights were given to the agency. No title 22 regulations were cited during today's inspection.

Investigation Findings:
13Licensing Program Analyst (LPA) Mary Shelton conducted a visit on March 30, 2022, and LPA spoke with Staci Exceus, 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 on 11/30/2021. The initial 10-day complaint inspection was conducted by LPA Mary Shelton, at the agency on 11/30/2021 and included a review of the facility and obtaining of relevant documents: Needs and Services, monthly treatment plan, supervised visit log, certificate of approval and training records. Additional interviews were conducted by LPA Mary Shelton, which included Reporting Party, C1, C2, S1, S2, S3, Administrator and Social Worker between 12/9/2021 and 3/23/22. C1 is currently placed back in the home. 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: CENTER FOR POSITIVE CHANGES 6FACILITY NUMBER: VISIT DATE: 03/30/2022

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


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts Mary Shelton and Dawn Eunice (LPA's) conducted an annual inspection to the above Agency (STRTP) for the purpose of ensuring compliance with the Health and Safety Code, Interim Licensing Standards and Title Regulations. LPA's completed the COVID- Symptom Self-Assessment and Affirmation Questionnaire, the Entrance Checklist, and Facility Inspection Checklist. LPA's toured the facility. There is a table located by the entrance of the facility and staff takes your temperature and a visitor's log. LPA's toured the facility. The over all facility as well as the kitchen is clean, safe, sanitary in good repair. There is adequate fresh, frozen and perishable food; fresh fruit is set out. There is menu posted on the refrigerator; children are allowed to participate in creating it. Cleaning cleaning supplies are locked The water temperature is between 105-120 degrees. The dining room accommodates the number of clients. There is a fire extinguisher located between the kitchen and dining area. There are two personal rights posters posted in the facility's common living area as well as a Foster Youth Bill of Rights poster. There are three bedrooms and only two are occupied by clients. The bedrooms are spacious enough to walk through with a lamp, dresser and closet space. The windows have screens and blinds/curtains, The smoke detectors meet the standards. There is a fire extinguisher located between the kitchen and dining area. The facility is equipped with linens and personal hygiene products. The bathroom was clean, sanitary and in good repair. The water and the temperature is between 105-120. The clients keep their hygiene products in their rooms. LPA reviewed children's medication/logs and the JV 220 forms if pertinent. LPA's inspected the outside area and a shed that is keep locked with yard maintenance tools, paint and a shop vac. Pursuant to SB 1264; amendment to the H&S Code 1565, the facility's emergency preparedness plan has been updated. The clients files are located at the facility and the staff files were brought to the facility for review. LPA's provided a copy of the Personnel History Report and requested they delete names of individuals who are no longer associated to the home. Additional information obtained/reviewed includes: Administrative offices are separate and secure, the STRTP offices provide privacy for interviewing children; additionally, LPA's interviewed three children and 3 staff. LPA's requested the following forms be updated and provided Ms.Staci Exceus printed blank copies of: LIC Administrative Organization, LIC Designation of Administrative Responsibility and LIC Personnel Report. LPA's reviewed the agency's board meeting minutes.. LPA's also requested to be updated on the National Accreditation 87089(C) and the Mental Health Certification 87089.1 by July 12, 2021. Based on staff and child interviews, there are appropriate staff/client ratios, the Licensee is in compliance with reporting requirements, staff is knowledgeable about emergency interventions and runaway plans, the Board of Directors meet at least quarterly, staff is knowledgeable about prudent parent standards, staff participate in Child and Family Teams meetings, staff indicate they follow identified services in children's needs and services plans, staff and children know what children's personal rights are and children feel safe and free to talk to staff if they have a problem or need to resolve an issue. Additionally, LPA's inspected the facility van; the van's tires appeared safe, the seat belts were operational and the service log book was maintained. LPA's conducted exit interview and provided business cards to staff and children. The facility is in substantial compliance with all mandates. There are no citations delivered today.

met_with: Administrator, Staci Exceus


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Mary Shelton conducted an unannounced inspection on 7-6-22 at 11: AM. LPA met with Maria Felise, Facility Manager and discussed the reason for the visit. LPA observed there was no furniture or personal items in the home. The clients have been relocated. LPA obtained the Licenses due to the closure. There is no longer Wi-Fi in the home. A copy of this report was emailed to Maria Felisa, Facility Manger.

met_with: Maria Felise, Facility Manager


facility_name: CENTER FOR POSITIVE CHANGES

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Narrative:
...CONTINUED A confidential interview indicated that C1 was called expletives and pushed to the ground by staff during the incident that led to C1 being placed on a hold. Conflicting confidential interviews and records reviewed indicated that proper techniques were utilized while restraining C1, that staff were supportive while attempting to de-escalate C1, and that no injuries were observed on C1 after the restraints ended. A confidential interview indicated that clients in care, including C1, were treated with respect and were not hurt by staff. Based on conflicting confidential interviews and records reviewed, the allegation that a minor is being verbally/physically abused while in care is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Paul Kelley, Administrator and a copy of this report and appeal rights were provided and explained.

Investigation Findings:
13On March 7, 2025, at 10: AM, Licensing Program Analyst (LPA) Jacob Salem met with Paul Kelley, Administrator of Center for Positive Changes 7 to deliver the finding for the above-stated allegation. LPA Salem initiated a complaint inspection at the facility on 8/27/2024 at 1: PM and no immediate deficiencies were observed. During the investigation, LPA Salem interviewed Staff (S1-S4), Clients (C1 and C2), and County Social Worker (CSW). LPA attempted to interview C3 but was unable due to C3 declining to be interviewed. Pertinent records were obtained and reviewed. On August 23, 2024, Community Care Licensing (CCL) received an allegation that a minor (C1) is being verbally/physically abused while in care. It was reported that staff were verbally and physically abusive to C1 prior to C1 being placed on a hold for dangerous behaviors, but that no injuries were observed on C1. Confidential interviews and records reviewed indicated that C1 was restrained multiple times during their three days living in the facility, due to C1's assaultive and self-harming behaviors. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Center for Positive Changesfacility Number: Visit Date: 03/07/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...CONTINUED A confidential interview indicated that C1 was called expletives and pushed to the ground by staff during the incident that led to C1 being placed on a hold. Conflicting confidential interviews and records reviewed indicated that proper techniques were utilized while restraining C1, that staff were supportive while attempting to de-escalate C1, and that no injuries were observed on C1 after the restraints ended. A confidential interview indicated that clients in care, including C1, were treated with respect and were not hurt by staff. Based on conflicting confidential interviews and records reviewed, the allegation that a minor is being verbally/physically abused while in care is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Paul Kelley, Administrator and a copy of this report and appeal rights were provided and explained. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of 4

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

met_with: Paul Kelley, Administrator


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Narrative:
...CONTINUED A confidential interview indicated that S1 would often leave C1 and C2 alone, which led to C2 touching C1 in a private area. A conflicting confidential interview indicated that S1 did not leave C1 and C2 alone together and would get another staff to supervise while using the bathroom. A third conflicting interview indicated that S1 did leave C1 and C2 alone, but no inappropriate touching occurred. Confidential interviews and records reviewed indicated that staff were actively addressing C1's poor boundaries with therapy and other services, including placing C1 on a strict one-to-one after the alleged touching. A confidential interview indicated that staff did not respond quickly during the above-mentioned chasing incident, but that the brick did not hit C1. Conflicting confidential interviews indicated staff promptly separated the clients after they started fighting and later pursued the clients when the altercation continued, in an effort to protect C1. LPA observations indicated that the facility installed a secured area that could be utilized by C2 for safety when C1 displayed aggressive behavior. Based on confidential interviews, records reviewed, and observations, the allegation that staff did not prevent inappropriate interactions between minors in care is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Ashley Brown, Designee and a copy of this report and appeal rights were provided.

Investigation Findings:
13On July 18, 2025, at 4: PM, Licensing Program Analyst (LPA) Jacob Salem met with Ashley Brown, Designee of Center for Positive Changes #7 (CFPC) to deliver the finding for the above-stated allegation. LPA Salem initiated a complaint inspection at the facility on 11/15/2024 at 12: PM and no immediate deficiencies were observed. During the investigation, LPA Salem interviewed Clients (C1 and C2) and Staff (S1-S5). Pertinent records were obtained and reviewed. On November 14, 2024, Community Care Licensing (CCL) received the allegation that staff did not prevent inappropriate interactions between minors (C1 and C2) in care. It was reported that C1 was inappropriately touched, chased, and hit with a brick by another client in the home, and that staff were absent during the incidents. Confidential interviews and records reviewed indicated that C1 has a history of inappropriate touching and physical aggression, especially toward female peers, and that these behaviors were directed at C2 while C1 was placed at CFPC. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Center for Positive Changesfacility Number: Visit Date: 07/18/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...CONTINUED A confidential interview indicated that S1 would often leave C1 and C2 alone, which led to C2 touching C1 in a private area. A conflicting confidential interview indicated that S1 did not leave C1 and C2 alone together and would get another staff to supervise while using the bathroom. A third conflicting interview indicated that S1 did leave C1 and C2 alone, but no inappropriate touching occurred. Confidential interviews and records reviewed indicated that staff were actively addressing C1's poor boundaries with therapy and other services, including placing C1 on a strict one-to-one after the alleged touching. A confidential interview indicated that staff did not respond quickly during the above-mentioned chasing incident, but that the brick did not hit C1. Conflicting confidential interviews indicated staff promptly separated the clients after they started fighting and later pursued the clients when the altercation continued, in an effort to protect C1. LPA observations indicated that the facility installed a secured area that could be utilized by C2 for safety when C1 displayed aggressive behavior. Based on confidential interviews, records reviewed, and observations, the allegation that staff did not prevent inappropriate interactions between minors in care is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Ashley Brown, Designee and a copy of this report and appeal rights were provided. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of 2

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

met_with: Ashley Brown, Designee


summary: Complaint Investigation - Unsubstantiated - 5 allegations

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Narrative:
...CONTINUED A confidential interview indicated that once C1 was inside the facility vehicle with staff, S1 spoke inappropriately to C1 by using a curse word one time due to having heightened adrenaline following C1 running into the street and C1 physically attacking S1; however, other interviewees present during the incident did not indicate C1 was physically aggressive with S1. Conflicting confidential interviews indicated that once C1 was in the facility car they became verbally abusive to S1, and in response S1 used verbally abusive language toward C1. Confidential interviews and records reviewed indicated that after the incident S1 received a disciplinary write-up for using inappropriate language with a client, as well as training on trauma informed care and de-escalation strategies. Based on confidential interviews and records reviewed, the allegation that staff verbally abused a minor is substantiated because the preponderance of evidence has been met. This posed an immediate Health, Safety, or Personal Rights risk to children in care, and the facility will be cited for violating Interim Licensing Standards for Short Term Residential Treatment Programs, Section 87072(c)(1). An exit interview was conducted, and a plan of correction was developed with Anne Ford, Residential Director. A copy of this report, appeal rights, and LIC 811 were provided to Anne Ford, Residential Director. ...CONTINUED Confidential interviews indicated that the facility was informed by C1's county social worker that C1 was not supposed to have a cell phone despite being provided one by a family member. A conflicting review of records indicated that this restriction was not written in C1's needs and services plan; however, a review of C1's signed facility electronic policy indicated that the facility informed C1 and their authorized representative upon placement that electronics, including cell phones, would be confiscated if they interfere with clients participating in services. Confidential interviews indicated that staff attempted to physically take the phone from C1 after they refused to turn it in; however, the same interviewees indicated that staff did not handle C1 roughly or intimidate C1 during the interaction. A conflicting confidential interview indicated that staff held on to the phone but did not try to take it from C1 and later confiscated the phone after C1 put it down. Based on confidential interviews and records reviewed, the allegation that staff inappropriately took a minor's phone away is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Anne Ford, Residential Director and a copy of this report and appeal rights were provided.

Investigation Findings:
13On August 12, 2025, at 12: PM, Licensing Program Analyst (LPA) Jacob Salem met with Anne Ford, Residential Director of Center for Positive Changes 7 to deliver the finding for the above-stated allegation. LPA Salem initiated a complaint inspection at the facility on 12/19/2024 at 10: AM and no immediate deficiencies were observed. During the investigation, LPA Salem interviewed Client (C1), Staff (S1-S5), a county social worker, and a service provider. Pertinent records were obtained and reviewed. On December 11, 2024, Community Care Licensing (CCL) received the allegation that staff (unnamed) verbally abused a minor (C1). It was reported that an unknown staff member was being verbally abusive to C1 after they left the facility without permission. Confidential interviews and a review of an incident report indicated that C1, who was nine years old at the time, became upset and left the facility without permission, leading to staff following and restraining C1 after they engaged in risky behavior by walking into the street between cars. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Center for Positive Changesfacility Number: Visit Date: 08/12/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...CONTINUED A confidential interview indicated that once C1 was inside the facility vehicle with staff, S1 spoke inappropriately to C1 by using a curse word one time due to having heightened adrenaline following C1 running into the street and C1 physically attacking S1; however, other interviewees present during the incident did not indicate C1 was physically aggressive with S1. Conflicting confidential interviews indicated that once C1 was in the facility car they became verbally abusive to S1, and in response S1 used verbally abusive language toward C1. Confidential interviews and records reviewed indicated that after the incident S1 received a disciplinary write-up for using inappropriate language with a client, as well as training on trauma informed care and de-escalation strategies. Based on confidential interviews and records reviewed, the allegation that staff verbally abused a minor is substantiated because the preponderance of evidence has been met. This posed an immediate Health, Safety, or Personal Rights risk to children in care, and the facility will be cited for violating Interim Licensing Standards for Short Term Residential Treatment Programs, Section 87072(c)(1). An exit interview was conducted, and a plan of correction was developed with Anne Ford, Residential Director. A copy of this report, appeal rights, and LIC 811 were provided to Anne Ford, Residential Director. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: CENTER FOR POSITIVE CHANGESFACILITY NUMBER: 374690076

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


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Narrative:
Record review further revealed the facility had requested and been approved to have a one-to-one staff assigned to C2, due to previous assaultive behaviors. Confidential interviews and record review provided consistent evidence regarding C1 receiving injuries caused by C2. Confidential interviews provided consistent statements revealing when the initial escalation occurred between C1 and C2, staff was not in the same room as C1 and C2. Based on confidential interviews and record review the allegation alleging staff did not prevent minor from physically assaulting another minor resulting in injuries is substantiated. The complaint allegation is valid because the preponderance of evidence standard has been met. Facility is cited for violation of Interim Licensing Standards (ILS) PERSONAL RIGHTS 87072 (c)(1) To live in a safe, healthy, and comfortable home where they are treated with respect. A copy of the report was discussed and provided along with appeal rights to Facility Administrator, Ashley McCallie.

Investigation Findings:
13On November 12, 2025 at 10:10 am Licensing Program Analyst (LPA), Raina Pere-Diaz met with Center for Positive Changes 7, Facility Administrator, Ashley McCallie, to deliver the finding for the above stated allegation. A Health and Safety inspection of the facility was conducted on 02/06/2025 by LPA Salem, and no immediate hazards were observed. The investigation was conducted by LPA Salem, LPA Ortega, and Perez-Diaz and included interviews with two of two foster children [Client #1 (C1) and Client #2 (C2)], three staff [Staff #1 (S1) - Staff #3 (S3)], and two county social workers [CSW1 and CSW3]. In addition, county records, and facility records were reviewed. On February 4, 2025, Community Care Licensing (CCL) received an allegation alleging staff did not prevent minor from physically assaulting another minor resulting in injuries. Specifically, it was reported that an incident occurred on facility ground on or about 2/2/2025, resulting in C1 being taken to the hospital. Record review revealed an incident did occur at the facility between C1 and C2. ***Continue LIC-812C*** 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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: CENTER FOR POSITIVE CHANGESFACILITY NUMBER: VISIT DATE: 11/12/2025

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

met_with: Facility Administrator- Ashley McCallie


summary: Facility Evaluation

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Narrative:
On June 12, 2024, at 1: PM, Licensing Program Analyst Jacob Salem (LPA), Licensing Program Managers (LPMs) Abdoulaye Traore and Cheraki Davis, Center for Positive Changes (CFPC) Chief Operating Officer Amber Jansen (COO) and President Deanna Mellos (PS) met virtually via Microsoft Teams for a Component II orientation. LPA and LPMs went over revisions and discussed the process for the application prior to licensure. LPM Traore advised the facility representatives to communicate with LPA Salem to complete the revisions. A pre-licensing inspection will be scheduled once the program statement is approved by the Department. A copy of this report was sent to COO Amber Jansen for signature. The original signed copy will be placed in the facility file.

met_with: Amber Jansen & Deanna Mellos


summary: Facility Evaluation

raw_content:
Narrative:
On July 9, 2024, at 9: AM, Licensing Program Analyst (LPA) Jacob Salem and Licensing Program Manager (LPM) Dawn Segura conducted an announced visit to the above facility and met with Center for Positive Changes Amber Jansen, Deanna Mellos, and Paul Kelly, for the purpose of conducting a pre-licensing inspection. LPA, LPM, and the applicants toured the facility inside and out. Currently there are no clients placed in the home. The applicant is applying to serve six ambulatory clients ages 6 to 12. LPA conducted component III of the orientation process and reviewed with the applicants Licensing requirements. The home is a one-story building with four bedrooms and two bathrooms which are set up as follows: · Bedroom #1 (Client) has two twin beds and will sleep two clients. · Bedroom #2 (Client) has two twin beds and will sleep two clients. · Bedroom #3 (Client) has one twin bed and will sleep one client. · Bedroom #4 (Client) has one twin bed and will sleep one client. · Kitchen and dining area, living room, large family room area and table, a laundry room, staff office, storage closet, backyard/patio area, and attached two car garage. The Emergency Disaster Plan, Personal Rights, and complaint procedures are posted outside the kitchen area of the home. The license will be posted as soon as it is issued. The client bedrooms are arranged so that no more than two clients will share a room, no room commonly used for other purposes will be used as a bedroom, and no bedroom serves as a passageway to another room. There is adequate closet space for the clients' belongings. Client mattresses, blankets, pillows, and linens are clean and in good repair. There is a smoke detector in two bedrooms and a carbon monoxide located in the open family room area. The two smoke detectors and the carbon monoxide detector were tested and are working properly. Both client bathrooms have working faucets measured to run at 118.7 and 116.1 degrees F, as well as shower and toilet that are in clean and operating condition. There are additional bath towels and basic toiletries located in a locked cupboard in the hallway area. Continued... ...CONTINUED The kitchen is clean and well maintained with adequate utensils, dishware, and appliances for food storage and preparation. The kitchen sink was measured at 117.1 degrees F. The kitchen contains perishable and non-perishable food supplies ready for clients to consume upon entry into the program. There are additional perishable food supplies located in the garage freezer. There is a trash can for storage of solid waste in the kitchen with a tight-fitting lid. The home's central air conditioning module was located in dining area and the home is kept at a comfortable temperature. There is a spacious living room area with a sofa chairs, TV, reading material, and recreational activities for clients to use for relaxation or visitation from family and friends. There is also space and recreational activities in the garage for visitation and therapy sessions to occur. The facility has supplies and appliances necessary for laundering clients' personal clothing. There is no fireplace. The home is well lit and passageways are free from obstructions. The backyard consists of a patio and yard area, and window screens around the facility were inspected. A first aid kit is readily accessible and located in the staff office cabinet. A fire extinguisher was present in the home and located in the kitchen. It was observed to be recently inspected by the fire department. Applicant stated there were no weapons/firearms in the home and harmful cleaning supplies are locked in the hallway closet and inaccessible to clients. Knives are locked in the staff office cabinet. There is no swimming pool. The backyard where clients will have access to play was completely fenced. The facility has telephone service on the premises. The client's files will be locked inside a cabinet in the staff office, and provisions will be made for confidential interviews with clients. The facility has a Emergency and Disaster Plan, which contains all the required procedures, such as provision of emergency power, storage and preservation of medications, and the location of utility shut off valves. The following deficiencies were observed: 1. Accessible Air Conditioning Unit with large running fan located in the backyard. 2. Three floor rugs without non-slip materials located inside 3. Small hole in the sliding door screen for the backyard. 4. Facility does not have provisions for ironing clothing 5. First Aid manual not present in kit. The request for a license will be forwarded to Licensing Program Manager Dawn Segura for final approval once the deficiencies are cleared. An exit interview was conducted. A copy of this report was provided to Amber Jansen & Deanna Mellos of Center for Positive Changes.

met_with: Amber Jansen, Deanna Mellos, Paul Kelley