summary: Facility Evaluation

raw_content:
Narrative:
On September 21, 2022 at 11: AM, Licensing Program Analyst (LPA) Charmetha White arrived at Discovery Adolescent Program IV, for the purpose of conducting a Required 2-Year inspection. LPA met with Evan Sahn, Program Director and Elizabeth Smith, Milieu Manager, and was granted access into the facility. The facility was toured at 11: AM both inside and out. The facility is a private pay mental health facility licensed to provide care and supervision services for sixteen (16) children, ages 11-17 years old, ambulatory only. The census at the time of the inspection was nine (9). The facility is two story, 8 bedroom, 7 bathroom house and it is set up as follows: Bedrooms: there are four bedrooms each, on opposite wings of the second floor, and separated by the staff station and classroom area. Each bedroom has two twin beds, which include two attached storage drawers; two separate closets; working lights; and non-operating windows. Bathrooms: there are three bathrooms on the first floor, and four bathrooms, two in each wing, on the second floor. Laundry rooms: there are a total of two laundry rooms, one in each wing on the second floor, and both remained locked. Dining Area: equipped with multiple tables and chairs. Kitchen: equipped with an electric stove, two ovens, 3 microwaves, a double door refrigerator, a double door freezer, a pantry, and a dishwasher. Classroom area: equipped with computers, chairs, TV, and bookshelves. Outdoor recreation area: there are two outdoor areas, one on each side of the dining room area. The areas are equipped with basketball court, ping pong table, and multiple sitting areas. Medication room: located on the first floor and remains locked. Report continued on LIC 809C. Staffing offices/Therapist rooms: there two staffing offices and five therapy offices. The carbon monoxide detectors were tested and found to be in working order. Facility fire alarm is hard wired and was not tested during inspection. Medications are locked medication room and made inaccessible to clients in care. Additionally, medications that require refrigeration is stored in a double locked refrigerator located in the medication room. First Aid Kit was checked and found to be complete. Sharp knives are stored in a locked box locked in the kitchen pantry. The facility has 7 regulation fire extinguishers. The facility has a working telephone readily accessible. Menu is posted in kitchen area. Facility has non-perishable foods for one week, perishable foods for two days, and clients are provided nutritious between meals. Temperatures in client rooms and common areas were found to be between 68 - 85 degrees (F). Hot water temperature was tested and found to be between 105 - 120 degrees (F). Disinfectants/cleaning solutions and poisons inaccessible to clients. Overall LPA observed the facility to be clean, safe, sanitary and in good repair. The front yard and outdoor recreation area were clean and free of debris. Passageways, stairways, inclines, ramps and open porches were unobstructed. There are no firearms or dangerous weapons in the facility. There was no swimming pool or bodies of water located at the facility. The facility operates within license conditions and limitations including capacity limitations. LPA discussed and advised the Licensee to ensure the following: Children are supported and encouraged to participate in extracurricular activities. Children are allowed and encouraged to contact the licensing agency or the Foster Care Ombudsperson, in confidence, without threats or punishment for making complaints. Children are accorded dignity in personal relationships with others in the home. LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. All posting requirements for Group Home Licensure and Emergency Plan were met. Program Director provided LPA with a copy of the Personnel Report (LIC 500). LPA will return to facility at a later time to review client and staff records. There are no deficiencies observed or cited at this site visit. Exit interview was completed and a copy of this report was left at the facility.

met_with: Evan Sahn- Program Director & Elizabeth Smith - Milieu Manager


state: CA

facility_name: DISCOVERY ADOLESCENT PROGRAM IV

summary: Facility Evaluation

raw_content:
Narrative:
On September 29, 2022 at 11: AM, Licensing Program Analyst (LPA) Charmetha White arrived at the above location for the purpose of reviewing staff and client records to complete the Required 2-Year Inspection which began on 09/21/2022. LPA met with the Program Director Evan Sahn and Milieu Manager Elizabeth Smith who granted access to location and provided the files. The Program has a total of twelve staff. LPA reviewed ten staff files, and interviewed five Staff. LPA observed all Staff records included annual personnel performance evaluations, all staff have met the education and experience requirements, and have completed the required training's. All staff that work directly with clients have current First Aid/CPR cards in their files. The Program currently has a total of eleven clients. LPA reviewed a total of four client files and interviewed a total of four clients. There were no deficiencies noted on this date. An exit interview was conducted and a copy of this report was signed and left with the Program Director.

report_type: Facility Evaluation

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On December 5, 2023, Licensing Program Analyst (LPA) Charmetha White made an unannounced visit to Discovery Adolescent Program IV, for the purpose of conducting a Case Management for Special Incident Report #11-2023-34-CM-08. The incident occurred 11/20/2023 and the incident report was received by the Department on 11/27/2023. LPA met with Program Director, Shelby Thirkill and and discussed the incident. During this visit, LPA conducted confidential interviews. LPA was informed that Client #1 and Client #2 are no longer in placement at the facility. LPA requested a copy of the following documents: LIC 500 and contact information for Client #1 and Client #2. Additional interviews will be conducted on a later date. Based on interviews and information gathered, this case management needs further investigation. Exit interview was conducted, and a copy of this report was left with the Program Director.

met_with: Shelby Thirkill - Program Director


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On September 18, 2025, at 9: AM, Licensing Program Analyst (LPA) Aimee Moratalla arrived at the above facility for the purpose of conducting an Annual/Random inspection of the group home. This is a private pay, two-story substance abuse and mental facility. LPA met with the Nurse, Ashley Carter who granted access to the facility. At 10: AM an in-depth tour of the interior and exterior of the facility was conducted with Milieu Manager (MM), David Woodall. The facility is licensed to provide care and supervision for sixteen (16) children ages 11-17 years old, ambulatory only. The census today is eleven (11). The home was inspected, and the following were observed: The facility is set as follows: Bedrooms: There is a total of eight bedrooms equipped with two twin beds each (located on the second floor; girls and boys on the opposite wings of the floor separated by a staff station and classroom area). Bathrooms: There are seven bathrooms (three on the first floor, four on the second floor), Laundry rooms: There are a total of two, both remained locked. There are two multi-purpose rooms downstairs, used for group therapy and a tv viewing with DVD player area. The kitchen and food storage area are all located on the 1st floor. On the 2nd floor, there is another multi-purpose area with computers and chairs. There are two outdoor recreation areas including a sports court and multiple activity/game options. The one on each floor which remained locked. The medication room is located on the 1st floor which remains locked with clients' medication. Offices/Therapy rooms are located on the 1st floor. The staff station is located on the 2nd floor. Page 1 of The facility is clean, safe, sanitary and in good repair. Passageways, stairways, inclines, ramps and open porches are unobstructed. Disinfectants/cleaning solutions and poisons inaccessible to clients. Hot water temperatures are maintained between 105 and 120 degrees (F). Children in care are always supervised & protected. Facility has non-perishable foods for one week and perishable foods for two days. The facility provides nutritious snacks and meals. Medications are locked and accessible only to employees supervising stored medications. Facility posts child's rights if licensed to provide foster care for six or more children. Children are not restricted in telephone use except by court order. Children accorded dignity in personal relationships with others in the home. Children live in a safe, healthy, comfortable facility and are treated with respect. Children can contact the licensing agency or foster Care Ombudsperson in confidence without threats or punishments for making complaints. Children attend school, extracurricular, cultural and personal enrichment activities. Facility maintains personal property and valuables. Facility operates within license conditions & limitations including capacity limitation. Program Administrator (PA), Blaise Eversole provided a copy of the Personnel Report (LIC 500) and Client Roster (LIC 9020). LPA conducted the LPA will return to the facility later to complete the annual visit. As per PA, the cameras in the facility are non-operational. All fire extinguishers were visually inspected on 9/1/25 by PA. Alarm system was tested and working. LPA reviewed the following sections: Physical plant, operations, and disaster preparedness. LPA reviewed the LIC Personnel Report and Guardian Roster. LPA informed the Program Manager that the following three (3) staff members: John Garcia, Sandra Mendoza, and Ashley Carter, who were working and present in the facility at the time of the inspection, were not associated to the facility per licensing regulations. The PA was informed that the facility will be cited for, 80019(e) Criminal Record Clearance; LPA will return at a later date to review client files and complete Staff file review. Exit interview was completed and a copy of this report will be emailed to the Program Administrator. Page 2 of 2

Deficiencies:
80019(e): Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility

visit_type: Annual

met_with: Program Administrator, Blaise Eversole


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On September 22, 2025, at 09: AM Licensing Program Analyst (LPA) Aimee Moratalla made an unannounced visit to the above facility for the purpose of conducting a Case Management - Annual Continuation inspection from the initial visit conducted on 9/18/2025. LPA was met by Milieu Manager (MM), David Woodall and informed him the purpose of the visit was to conduct and complete the Annual inspection. LPA inquired about the current census, requested the staff roster. LPA requested staff and client files, and MM sat with LPA because the files are stored electronically through Kipu App and Workforce App. At the time of the visit the census is one (1). File reviews: LPA conducted 3 staff files and 3 client files. Interviews Conducted: 3 staff and 3 clients During the time of inspection, LPA completed the related Care Tools and addressed the following sections: Clients and staff files, interviews, and emergency intervention plan. PER California Code Regulations, TITLE 22, DIVISION 6, CHAPTERS 5, General Licensing Regulations the following deficiencies were observed and cited at the time of this inspection, 80066(a)(12)(B)(1) Personnel Records; 84064(b) Administrator Qualifications and Duties. An exit interview was conducted, and the Program Administrator was informed that the Annual Inspection was completed. A copy of this report will be emailed to the Administrator.

Deficiencies:
84064(b): Deficient Practice Statement
1
2
3
4Based on interview and record review, the licensee did not comply with the section cited above which is not having a current and valid Administrator certificate which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
1
2
3
4

title:
Administrator Qualifications and Duties

(b) Effective January 1, 2000, all group homes shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Confidential witness statements indicated that facility staff (S1 and S2) were conducting bedroom checks throughout the night every 15 minutes. Confidential witness statements revealed that C1 hid C2 under C1's blankets as facility staff conducted their routine bedroom checks. Confidential interviews stated that C1 and C2 did not remember the names of the facility staff on shift that night. Confidential witness statements disclosed that the allegation could not have happened on S1 and S2's night shift. Confidential interviews indicated that S1 and S2 are alert during their shifts. Confidential witness statements indicated that S1 and S2 conducted body and breath checks every 15 minutes and that all clients were asleep. Confidential witness statements indicated that S1 and S2 did not observe clients outside their bedrooms. Confidential witness statements disclosed that C2 would need to walk across the main common area where S1 or S2 were positioned to get to C1's bedroom on the opposite side of the facility. It is unknown which staff was on shift during the incident. Although confidential interviews stated that S1 and S2 did not observe clients outside their bedrooms, C1 and C2 engaged in consensual inappropriate sexual interactions during the staff night shift. Based on confidential interviews, the preponderance of evidence standard has been met, and the allegation that the minors (C1 and C2) engaged in inappropriate sexual interactions and staff are not providing adequate supervision is substantiated. The facility is cited for violation of Children's Residential Group Home Title Division Chapter Article Continuing Requirements 84065. Personnel Duties (b) Child care staff shall perform the following duties: (1) Supervision, protection and care of children individually and in groups at all times. Confidential witness statements disclosed that C1 and C2 engaged in inappropriate sexual interactions, and staff are not providing adequate supervision, which poses an immediate Health, Safety, or Personal Rights risk to children in care. An exit interview was conducted, appeal rights were explained, and a copy of this report was provided to Discovery Mood & Anxiety Program Riverside Facility Chief Executive Officer (FCEO) John Smith.

Investigation Findings:
13On October 19, 2023, at 12:16 pm, Licensing Program Analyst (LPA) Jose Gonzalez conducted an unannounced visit and met with Discovery Mood & Anxiety Program Riverside Facility Chief Executive Officer (FCEO) John Smith to deliver the findings for the above-stated allegation. LPA inspected Discovery Mood & Anxiety Program Riverside Group Home at 11:19 am on March 9, 2023; no health and safety hazards were observed. LPA reviewed two client's records (C1 and C2). During the investigation, interviews were conducted with six clients (C1, C2, C3, C4, C5, and C6), the Program Director (PD), the Education Liaison (EL), and two Facility Staff (S1 and S2). The Department received an allegation on March 3, 2023, that the minors (C1 and C2) engaged in inappropriate sexual interactions, and staff are not providing adequate supervision to minors (C1 and C2). Confidential witness statements disclosed that inappropriate sexual interactions occurred in C1's bedroom. Confidential witness statements revealed that C2 snuck out of their bedroom and placed clothes underneath their blankets to make it appear as if C2 was in bed sleeping.**CONTINUED on LIC 9099C** SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Jose Gonzalez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: DISCOVERY MOOD & ANXIETY PROGRAM RIVERSIDEFACILITY NUMBER: VISIT DATE: 10/19/2023

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

report_type: Complaint Investigation

complaint_status: SUBSTANTIATED


raw_content:
Narrative:
Confidential witness statements indicated that the facility staff nurse (FN) and facility staff (FS) instructed C1 to remove their clothes from their underwear and put on the hospital gown provided by the facility staff. Confidential witness statements revealed that the FN and FS conducted a "body check" of C1. Confidential witness statements revealed that the body check consisted of C1 undressing down to their underwear and putting on the hospital gown provided. Confidential interviews stated that FN and FS instructed C1 to remove their clothes and underwear and for C1 to put on a hospital gown. Confidential interviews stated that FS and FN never instructed C1 to remove their underwear. Confidential interviews indicated that C1 was not provided with a safe and comfortable environment. Confidential witness statements disclosed that C1 did not feel comfortable and safe during the "body check." Confidential interviews stated that C1 felt vulnerable and violated during the "body check" procedure. Confidential witness statements indicated that C1 was not treated with dignity and respect. Confidential interviews stated that C1 did not want to complete a "body check." Confidential witness statements disclosed that C1 needed to complete a "body check" and was part of the admission intake process. Confidential interviews indicated that they were aware of the "body check" procedure as part of the intake process but unaware of the details of clients having to remove all their clothes and put on a gown. Confidential interviews stated that it was not indicated on the intake form that C1 was to undress down to their underwear and that C1 would be provided with a hospital gown to wear as FN and FS checked C1 for bruises, injuries, and marks. Based on confidential interviews and record review, the preponderance of evidence standard has been met, and the allegations that the staff violated the minor's (C1) personal rights, staff did not treat the minor (C1) with dignity and respect, and the staff did not provide a safe and comfortable environment are substantiated. The preponderance of evidence standard has been met. The facility is being cited for violation of the California Code Regulations Title Division Chapter Article Continuing Requirements, section Personal Rights (d) The licensee shall ensure that each child, regardless of whether the child is in foster care, is accorded the personal rights specified in Welfare and Institutions Code section 16001.9...Confidential witness statements disclosed that staff violated C1's personal rights and did not provide a safe and comfortable environment for C1, which poses a potential Health, Safety, or Personal Rights risk to children in care. An exit interview was conducted, appeal rights were explained, and a copy of this report was provided to Discovery Mood & Anxiety Program Riverside Facility Chief Executive Officer (FCEO) John Smith.

Investigation Findings:
13On April 29, 2024, at 11:48 am, Licensing Program Analyst (LPA) Jose Gonzalez conducted an unannounced visit and met with Discovery Mood & Anxiety Program Riverside Facility Chief Executive Officer (FCEO) John Smith to deliver the findings for the above-stated allegations. LPA inspected Discovery Mood & Anxiety Program Riverside Group Home at 9:23 am on June 20, 2023; no health and safety hazards were observed. LPA reviewed two client's records (C1 and C2). During the investigation, interviews were conducted with five clients (C1, C2, C3, C4, and C5), the Program Director (PD), the Facility Nurse (FN), and a Facility Staff (FS). The Department received an allegation on June 16, 2023, that the staff violated the minor's (C1) personal rights, the staff did not treat the minor (C1) with dignity and respect, and the staff did not provide a safe and comfortable environment for C1. Confidential witness statements disclosed that facility staff violated C1's personal rights. R- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: DISCOVERY MOOD & ANXIETY PROGRAM RIVERSIDEFACILITY NUMBER: VISIT DATE: 04/29/2024

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


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews indicated that the maintenance workers repaired all broken fixtures, furniture, and tiles. Other confidential interviews indicated that the facility has a housekeeper who cleans the facility's common area, nurses' station, staff offices, and staff restrooms. Confidential interviews revealed that the housekeeper cleans the clients' bedrooms, restrooms, and dining areas. Confidential interviews stated that all broken furniture and fixtures are reported to administrative staff to submit a request for maintenance repairs. The Department also received a second allegation that the facility staff does not provide staff/client ratio care and supervision to minors. Confidential interviews indicated that the facility maintained one staff per eight clients ratio. Other confidential interviews indicated that the staff-to-client ratio is one staff per six clients. Confidential interviews stated that the nurse will assist with supervision when staff leave on break. Confidential interviews revealed that administrative staff and nurses are utilized to ensure the facility maintains one staff per six-client ratio. During the inspection, LPAs and LPM observed one staff per four clients at the facility. The Department also received a third allegation that the facility does not have trained staff to meet the minor's medical needs. Confidential interviews indicated that the staff does not know how to check the client's vitals or properly distribute medication to clients. Confidential interviews indicated that the facility nurse manager (NM) trains particular staff to check the client's vitals and dispense medication. Confidential interviews stated that NM would monitor the staff to check the client's vitals and dispense medications to ensure the staff followed the procedure. Confidential interviews indicated that there is a nurse on duty every shift: morning, afternoon, and overnight. Confidential interviews stated that not all the clients need their vitals checked before and after medication passing. The Department also received a fourth allegation that the facility staff does not ensure minors are provided adequate food service. Confidential interviews revealed that the facility staff do not have a food handlers' card. In addition, confidential interviews also stated that leftover meals are left on the counter for hours. During the inspection, LPA observed the food handler cards in the staff facility file and did not observe food being left on the kitchen counters. Confidential interviews stated that the facility has a lead chef (LC) and a weekend chef (WC). Confidential interviews indicated that LC prepares and cooks lunch and dinner during the week. Confidential interviews stated WC prepares and cooks lunch and dinner on the weekends. ******CONTINUED on LIC 9099C****** Confidential interviews indicated that meal leftovers are stored in plastic Ziplock bags and containers after the food has cooled down, labeled with the date the meals were cooked, and stored inside the refrigerator by LC and WC. Confidential interviews indicated that the leftover meal is discarded three days after the date the meals were cooked. Confidential interviews stated the facility staff served the clients prepackaged food for breakfast, such as cereal, bagels, milk, and juice. Confidential interviews indicated the facility staff cooks and prepares the meals. The Department also received a fifth allegation that the facility staff does not ensure the facility is free of insects. Confidential interviews revealed that they had observed flies and roaches inside the facility. Confidential interviews indicated that they had not seen an infestation of insects inside the facility. However, other confidential interviews stated that they have occasionally observed a fly and spider inside the facility. Confidential interviews stated that pest control sprays the inside and outside of the facility every three months. Based on inconsistent confidential interviews and facility record review, the facility staff does not ensure the facility is clean, safe, sanitary, and in good repair at all times for the safety and well-being of clients, the facility staff does not provide staff/client ratio care and supervision to minors, the facility does not have trained staff to meet minor's medical needs, the facility staff does not ensure minors are provided adequate food service, the facility staff does not ensure minors are provided sufficient food service, and the facility staff does not ensure facility is free of insects are 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, appeal rights were explained, and a copy of this report was provided to Discovery Mood & Anxiety Program Riverside and met with Program Director (PD) Olevia Labeeb.

Investigation Findings:
13On September 17, 2024, at 11:07 am, Licensing Program Analyst (LPA) Jose Gonzalez conducted an unannounced visit and met with Discovery Mood & Anxiety Program Riverside Program Director (PD) Olevia Labeeb to deliver the findings for the above-stated allegations. LPA inspected Discovery Mood & Anxiety Program Riverside Group Home at 9:00 am on June 19, 2024; no health and safety hazards were observed. LPA reviewed six client's records (C1, C2, C3, C4, C5, and C6). During the investigation, interviews were conducted with six clients (C1, C2, C3, C4, C5, and C6), the Lead Chef (LC), the Nurse Manager (NM), the Mental Health Technician (MT), the Education Liaison (EL), and the Interim Program Administrator/ Milieu Manager (MM). The Department received a complaint on June 11, 2024, that the facility staff does not ensure the facility is clean, safe, sanitary, and in good repair at all times for the safety and well-being of clients. Confidential interviews indicated they observed mold in the bathrooms, and some floor tiles were lifting. *R- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: DISCOVERY MOOD & ANXIETY PROGRAM RIVERSIDEFACILITY NUMBER: VISIT DATE: 09/17/2024

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

met_with: Program Director (PD) Olevia Labeeb

complaint_status: unsubstantiated


raw_content:
Narrative:
Confidential interviews indicated that the administrator informed S1 not to be alone with C1 to prevent an allegation. Confidential interviews revealed that C1 was not inappropriately touched at the facility and that the alleged incident occurred at C1's previous placement. Confidential interviews stated that it was never witnessed that S1 or any other staff member attempted to touch C1 or any other clients residing at the facility. The Department also received a second allegation that the staff spoke inappropriately to the minor (C1). Confidential interviews indicated that facility staff did not speak to the clients inappropriately and spoke to them with respect. Confidential interviews stated that C2, C3, and C4 never heard staff speaking inappropriately to C1. The Department also received a third allegation that a staff allowed a minor (C1) to leave the facility. Confidential interviews indicated that the facility staff would encourage C1 to leave the facility. Confidential interviews revealed that a C1 was unhappy at the facility and wanted to be transferred to a different program. Confidential interviews revealed that C1 was directed to call their parents and inform them of C1's disappointment with the facility. Confidential interviews indicated that C1 walked out of the facility. Confidential interviews disclosed that the program director (PD) and milieu coordinator (MC) followed C1. Other confidential interviews indicated that the program director allowed C1 to leave the facility. Confidential interviews revealed that PD and MC encouraged C1 to make a better choice and return back to the facility. The Department also received a fourth allegation that the staff did not properly report incidents involving minor (C1) to an authorized representative. Confidential interviews stated that the facility staff did not properly report incidents to C1's authorized representative. Confidential interviews revealed that the administrative staff, management, and therapist report all incidents to C1's authorized representative. Confidential interviews stated that the administrative staff, management, and therapist instruct the facility staff to report an incident to the client's parents if they are off-site or after hours. In addition, confidential interviews also stated that the milieu coordinator (MC) reports all incidents to the client's authorized representative after hours. Based on inconsistent confidential interviews and facility record review, the allegations that staff (S1) inappropriately touched the minor (C1), staff spoke inappropriately to the minor (C1), staff allowed minor (C1) to leave the facility, and staff did not properly report incidents involving the minor (C1) to an authorized representative are unsubstantiated.****CONTINUED on LIC 9099C**** 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, appeal rights were explained, and a copy of this report was provided to Discovery Mood & Anxiety Program Riverside and met with Milieu Manager (MM) Marcus Gitchuway.

Investigation Findings:
13On October 18, 2024, at 11:00 am, Licensing Program Analyst (LPA) Jose Gonzalez conducted an unannounced visit and met with Discovery Mood & Anxiety Program Riverside Milieu Manager (MM) Marcus Gitchuway to deliver the findings for the above-stated allegations. LPA Jessica Peete inspected Discovery Mood & Anxiety Program Riverside Group Home at 10:55 am on May 14, 2024; no health and safety hazards were observed. LPA reviewed four client's records (C1, C2, C3, and C4). During the investigation, interviews were conducted with three clients (C1, C2, and C3), the Educational Liaison (EL), the Milieu Coordinator (MC), and the Interim Program Administrator/ Milieu Manager (MM). Due to C1's continual behavioral issues, it was determined that in C1's best interest, an interview with C1 would not be conducted during the investigation. On May 10, 2024, the Department received an allegation that the staff (S1) inappropriately touched a minor (C1). Confidential interviews indicated that staff (S1) never touched C1 inappropriately. *R- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, MAIN ST., SUITE FACILITY NAME: DISCOVERY MOOD & ANXIETY PROGRAM RIVERSIDEFACILITY NUMBER: VISIT DATE: 10/18/2024

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

met_with: Milieu Manager (MM) Marcus Gitchuway


raw_content:
Narrative:
This is an amended LIC9099C to the original issued on February 20, 2025. In addition, confidential interviews affirmed that S1 was suspended from working at the group home pending an investigation. Further, additional information indicated that S1 was detained for inappropriate sexual contact with C1. Based on confidential interviews and documentation, the allegation that a minor (C1) was inappropriately touched by staff (S1) while in care is substantiated. The preponderance of evidence standard has been met. The Group Home is cited for violation of Title California Code of Regulations (CCR) Personal Rights 84072 (d)(19) which states (d) The licensee shall ensure that each child, regardless of whether the child is in foster care, is accorded...personal rights (19) To be free of physical, sexual, emotional, or other abuse...exploitation ...coercion...or other actions of a punitive nature including, but not limited to, interference with the daily living functions of eating, sleeping. An Enhanced Civil Penalty (ECP) determination is pending. If an ECP is assessed a CCL representative will return to the facility to deliver the penalty assessment. The Program Administrator approved the assessment of this Enhanced Civil Penalty. Therefore, an ECP was issued to this facility in the amount of $5,000 on the {LIC809 and LIC421} An exit interview was conducted and a copy of this report, LIC 811, LIC 809D, and appeal rights were provided to Administrative Director Kaydeese Washington.

Investigation Findings:
13On February 20, 2025, at 9: AM, Licensing Program Analyst (LPA) Jessica Peete conducted an unannounced visit to Discovery Mood and Anxiety Program Group Home and met with Administrative Director, Kaydeese Washington to deliver the investigative findings for the allegation listed above. On 09/20/ LPA Peete initiated the investigation at the Group Home and collected pertinent documents to assist with the investigation process. The investigation was conducted by Special Investigator Dennis Douglas of the Community Care Licensing (CCL). The investigation included interviews with group home clients (C1-C3), staff (S1-S5), and Law Enforcement. On September 14, 2024, Community Care Licensing (CCL) received an allegation that a minor (C1) was inappropriately touched by staff (S1) while in care. It was alleged that S1 had separate instances of inappropriate contact with C1, including, but not limited to, the touching of C1's private areas over the clothes. During the investigation investigator Douglas obtained information that revealed C1 provided consistent statements regarding the alleged misconduct perpetrated by S1. (Continued on LIC 9099C) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Jessica M Peete LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION PACIFIC INLAND CR, MAIN ST., SUITE FACILITY NAME: DISCOVERY MOOD & ANXIETY PROGRAM RIVERSIDEFACILITY NUMBER: VISIT DATE: 02/20/2025

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

met_with: Kaydeese Washington Administrative Director


facility_name: DISCOVERY MOOD & ANXIETY PROGRAM RIVERSIDE

summary: Facility Evaluation

raw_content:
Narrative:
On November 03, 2022 at 9: AM, Licensing Program Analysts (LPA) Jessica Peete, and Licensing Program Manager (LPM), Cheraki Davis, conducted an unannounced annual inspection at Discovery Mood and Anxiety Program Group Home. LPA and LPM were met at the facility by Program Director Sylvia Parron at 9: AM. LPA and LPM began a physical plant inspection at 9: AM assisted by the Program Director and Milieu Manager Stephanie Rosales. The physical plant inspection included the following checks: A physical plant inspection was completed and included the facilities formal entry, kitchen area, dining room, refrigerator/freezers, food storage areas, two group rooms, two staff bathrooms, and two staff offices. There are three client wings (Green Wing, Blue Wing and Yellow Wing) All wings, except for the Yellow Wing, have three client bedrooms, one therapy office and one client bathroom. The Yellow wing had three client bedrooms, two client bathrooms and one therapy office. The facility grounds are clean and free of debris and observable hazards. Per Program Director there are no guns or weapons on facility grounds. Cleansers, chemicals, and cooking knives are inaccessible to clients. Cleaners and chemicals are locked in the front closet near the front door. Sharps are in a lock box located in the milieu (common area) and the cooking knives are locked in a cabinet in the kitchen. Licensee maintains an adequate supply of perishable and non-perishable foods and the food menus are posted. LPA observed the following postings: the facility license, Grievance Procedures, Visitation Policies and Personal Rights form. Age appropriate toys, games and books were observed for client's recreation time. There is adequate indoor and outdoor activity space, and all exits were free from obstruction. LPA observed the facility pool in the backyard to be inaccessible clients. The fence around the pool has a self-latching gate that swings outward and measured over five feet tall. The pool is clean and well maintained. (Continued on LIC C) All facility smoke detectors and carbon monoxide detectors are in appropriate working order and located throughout the facility. Fire extinguishers are properly charged and serviced and located throughout the facility. Medications are centrally stored inside the nurses' office and locked in a portable medication cart. The washer and dryer are located inside the facility near the Green Wing. All detergents are kept locked in a cabinet and are inaccessible to clients. All bedrooms have individual beds, the facility ensures that there are two client per bedroom, with appropriate linens, pillows, comforters, and mattresses in good repair. There is adequate drawer space for each client's belongings. The hot water in the client's bathroom was measured in each wing and were within 105-120 degrees Fahrenheit. At 9: AM LPA observed that the licensee did not comply with California Code of Regulations (CCR) 84072(a) Each facility licensed to provide foster care for six or more children shall post a listing of a foster child's rights. The licensee did not have the foster child's rights posted. At 10: AM LPA observed that licensee did not comply with (CCR) 80088(f)(1). (f) Solid waste shall be stored, located, and disposed of in a manner that will not transmit communicable diseases or odors.... (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof. LPA observed the trash can in the kitchen and bathrooms did not have lids. The facility has a total of three vehicles, labeled V#1, V#2 and V#3. All are used to transport clients to appointments and recreational activities. At 11: AM LPA observed that V#2 had a crack in on the passenger side windshield violating CCR 80074(c) Motor vehicles used to transport clients shall be maintained in a safe operating condition. At 11: AM LPA began the review Disaster Preparedness with the Program Director and Milieu Manager. All the documentation pertaining to this area of the inspection was provided, and no deficiencies were noted. At 12: PM LPA began the review of the Operational Requirements assisted by the Program Director and Milieu Manager. At 1: PM LPA observed the licensee was not in compliance with CCR 80020(a). All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. (Continued on LIC C) The licensee could not provide proof of fire clearance for the garage that was converted into a group room. Due to time constraints, LPA's will return to complete the inspection at a later date. An exit interview was conducted, and a copy of this report and appeal rights were provided to Program Director Sylvia Parron. This is an amended report of a report that was originally issued on 11/03/2022.

met_with: Sylvia Parron Progam Director , Stephanie Rosales Milieu Manager


summary: Facility Evaluation

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Narrative:
On 11/04/2022, at 9: AM, Licensing Program Analysts (LPA) Jessica Peete and Licensing Program Manager (LPM), Cheraki Davis, conducted an unannounced Annual Continuation visit at Discovery Mood and Anxiety Program Group Home. LPA Peete was met by the facility by Program Director Sylvia Parron at 9:40am. LPA Peete and LPM Davis visited the facility on 11/03/2022 to complete inspection of the Physical Plant, Operational Requirements and Disaster Preparedness. At 10: AM LPA began the review of the Emergency Interventions assisted by Milieu Manager Stephanie Rosales. All the documentation pertaining to this area of the inspection was provided, and no deficiencies were noted. At 10: AM LPA began the review of the Client Records assisted by Milieu Manager Stephanie Rosales. Five client records were reviewed (C1-C5) . At 12: LPA observed licensee did not comply with California Code of Regulations (CCR) 80069(c)(1). The regulation is stated as follows: (c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases. The licensee did not have the results of a tuberculosis examination for #C1, C3, and C4. As part of the Plan of Correction the licensee will provide tuberculosis results for the clients noted above. At 12: PM LPA observed the licensee did not comply with CCR 84069.1(a). The regulation is stated as follows: (a) A child for whom vaccination against the following diseases cannot be verified shall receive the first doses of the appropriate vaccines within 30 calendar days of placement in the facility and shall receive follow-up doses as recommended by the physician who administered the first doses. (Continued on LIC C) The licensee did not have the immunization record #C2, #C3, and an incomplete immunization record for #C4. As part of the plan of correction the licensee will provide the immunization records to include proof of immunization for the following: Poliomyelitis, Diphtheria., Pertussis,i.e.,whooping cough, Tetanus, Measles. Rubella, i.e., German measles, and Mumps for the clients noted above. At 1: PM LPA began the review of the Staff Records assisted by Milieu Manager Stephanie Rosales and Human Resource Compliance Specialist Sima Fotoohi. Five staff records were reviewed (S1-S5). All the documentation pertaining to this area of the inspection was provided, and no deficiencies were noted. Due to time constraints, LPA's will return to complete the inspection at a later date. An exit interview was conducted, and a copy of this report and appeal rights was provided to Milieu Manager Stephanie Rosales

met_with: Stephanie Rosales Milieu Manager


summary: Facility Evaluation

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Narrative:
On 11/09/2022, at 9: AM, Licensing Program Analysts (LPA) Jessica Peete conducted an unannounced annual continuation visit at Discovery Mood and Anxiety Program Group Home. LPA Peete was met by Milieu Manager Stephanie Rosales 9: AM. LPA visited the facility on 11/03/2022 and 11/04/2022 to complete inspection of the physical plant, operational requirements, disaster preparedness, client records and staff records. At 9: AM LPA interviewed three clients (C1,C5,C6). At the time of today's inspection C3 was not available for interviews, C2 and C4 were not on facility grounds. At 11: AM LPA conducted five staff interviews (S1,S3,S6,S7,S8). During today's inspection S2 and S5 were not on site. At 12: PM LPA continued with staff file reviews assisted by the by Milieu Manager. All required documentation pertaining to this area of the inspection was provided and no deficiencies were sited. Based on observations made during the inspection, no deficiencies were observed during today's visit an exit interview was conducted and a copy of this report and appeal rights were given to Milieu Manager Stephanie Rosales.


facility_name: DREAM HOME RESIDENTIAL

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Narrative:
Evidence obtained revealed that RP & Staff denied that Staff hit youth in care. Also, confidential interviews with Child 1 stated Staff did not hit him and he felt safe. Child 2 denied that Staff hit child in care. Child 3 was not able to answer questions due to to disability. Based on the interviews conducted and documentary evidence obtained the information did not produce corroborating evidence to support the above said allegations. Due to inconsistent statements LPA Phillips was not able to determine if the above said allegations occurred, therefore the allegations are found to be Unsubstantiated meaning that although the allegation may have happened or is valid there is not a preponderance of evidence to prove that the alleged incidents occurred. No deficiencies cited at the time of this investigation. Exit interview was conducted, and copy of this report was left with facility administrator.

Investigation Findings:
13On October 27, 2021 at 3:30PM Licensing Program Analyst (LPA), Zena Phillips conducted a follow-up complaint investigation visit to Dream Home Residential and met with Leah Hawkins, Administrator. The purpose of the visit was to deliver findings for the above complaint allegations. During the course of investigating the allegations: Facility staff hit youth. Facility staff handled youth in a rough manner. LPA Phillips conducted confidential interviews with related parties, reviewed facility records and Incident Reports. Based on the interviews conducted and statements obtained during the investigation the above allegations cannot be substantiated because LPA Phillips obtained inconsistent statements from RP, staff and residents in care. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Zena Phillips LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: DREAM HOME RESIDENTIALFACILITY NUMBER: VISIT DATE: 10/27/2021

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

met_with: Leah Hawkins/ Administrator


summary: Complaint Investigation - Unsubstantiated

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Investigation Findings:
13On March 18, 2021, Licensing Program Analyst (LPA) Bernice Karnsrithong arrived at the facility to conduct a follow-up complaint inspection. LPA met with Leah Hawkins, Administrator. The purpose of the visit was to deliver findings for the above complaint allegation. During the investigation of the allegation that minor was hit by another minor while in care, LPA Karnsrithong conducted confidential interviews and reviewed documentary evidences. Confidential interviews indicated that although an incident occurred between clients while in care resulting to minor injuries, staff provided appropriate emergency intervention and first aid. The facility provides one-on-one direct care staff that supervises clients who have special needs while they are in the facility to support when such incidents occur. Authorized parties were notified in a timely manner regarding the incident and appropriate behavior intervention plans were administered at the time of the incident. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. Therefore, the allegation is unsubstantiated. There are no deficiencies cited at this time. Exit interview was conducted with administrator and copy of the report will be provided. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Bernice Karnsrithong 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 1

met_with: Leah Hawkins,Administrator


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Investigation Findings:
13On April 27, 2023 at 11: AM, Licensing Program Analyst (LPA) C. White conducted an unannounced visit to the above facility for the purpose of delivering findings on the above allegations. LPA met with Facility Manager, Tammy Eldridge and discussed the findings. During the course of this investigation, LPA interviewed pertinent parties and reviewed records. Staff denied the allegations. Staff stated clients bathe each morning prior to getting dressed for school. Staff stated Client #1 attended school in short pants once and that the client is sent to school in uniform pants regularly. Staff stated appropriate clothing is provided for the clients in care. Staff stated Client #1 has a history of self injurious behavior and that the client's mother is aware of this. Staff stated clients in care are not neglected or abused by any staff. Client interviews did not produce corroborating evidence to support the allegations. LPA was unable to obtain a statement from Client #1 as the client is non-verbal. Based on information obtained, the allegations are found to be unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violations did or did not occur. No deficiencies cited. Exit interview completed and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Charmetha White 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 3

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

met_with: Facility Manager - Tammy Eldridge


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Investigation Findings:
13On 10/30/2024 at 8:30 am, Licensing Program Analyst (LPA) Justine Armstrong and Regional Manager Bernice Karnsrithong concluded the investigation of the above complaint allegations. LPA Armstrong met with with Greg Lilly Direct Staff Provider at the facility and Facility Manager Tammy Eldridge. During the investigation of the allegations, Staff member physically abused minor in care. LPA Justine Armstrong conducted confidential interviews and reviewed documentary evidence. Confidential interviews indicated that staff hit the minor while in care during a visit to the hospital. The staff did not follow emergency and crisis intervention procedures at the time the incident occurred. Facility cited for violation of California Code of Regulations, Title Division Six, regulation 80072(a)(3) Personal Rights. The exit interview was conducted with Gregory Lilly and a copy of this report was provided to the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Bernice Karnsrithong LICENSING EVALUATOR NAME: Justine Armstrong LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: DREAM HOME RESIDENTIALFACILITY NUMBER: 198209661

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

met_with: Gregory Lilly


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Investigation Findings:
13On 10/30/ Licensing Program Analyst (LPA) Justine Armstrong and Regional Manager Bernice Karnsrithong arrived at Dream Home Residential for the purpose of delivering findings for the allegation Child ingested a battery due to lack care & supervision LPA met with Greg Lilly Direct Staff Provider and Facility Manager Tammy Eldridge. at the facility. A Health and safety risk assessment was conducted upon arrival.During the investigation, the LPA conducted confidential interviews and reviewed several documents, including the staff crisis intervention training certificate, clients' personal summary logs, clients' behavior support plans, and shift duty expectations. Staff members denied the allegation. The LPA determined that the allegations were unsubstantiated based on the confidential interviews and documentary evidence. There is not enough evidence to establish a preponderance of the evidence to prove the alleged violation did or did not occur. There were no deficiencies cited. An exit interview was completed, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Bernice Karnsrithong LICENSING EVALUATOR NAME: Justine Armstrong 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 1


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Investigation Findings:
13On 11/22/2024, at 3: PM, Licensing Program Analyst (LPA) Kim Dear and Licensing Program Manager, (LPM), Enrique Hernandez, arrived at the facility to deliver findings for complaint investigation 34-CR-20240808123404. LPA met with Licensee, Leah Hawkins. and a health and safety assessment was conducted. During the investigation, LPA conducted confidential interviews and reviewed documentary evidence. Statements that were inconsistent and did not produce corroborating evidence to support staff physically abused minor in care. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. There were no deficiencies cited. An exit interview was completed, and a copy of this report will be emailed to Lisensee. There were no deficiencies cited. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Enrique M Hernandez LICENSING EVALUATOR NAME: Kim Dear 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 1

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


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Narrative:
The investigation further included review of client file, incident reports and review of facility file history as well as, review of medical forensic exam report, and Los Angeles Police Department (LAPD) investigative report. In addition, confidential interviews were conducted with two youth, two staff members, Administrator, and contacts with, assigned Quality Assurance Specialist-South Central Los Angeles Regional Center, LAPD, and Department of Children and Family Services (DCFS) assigned Emergency Response Social Worker. Record review revealed C1 resided at Dream Home Residential from December 2024 through 2/25/2025. The investigation uncovered several inconsistencies with the allegations. Documentary evidence from medical records and confidential interviews revealed inconsistencies as interviews found conflicting answers to questions asked by medical staff concerning specific accounts and dates of alleged sexual abuse. Confidential interviews by Investigator Santana also revealed inconsistencies. Statements obtained denied seeing any form of abuse or any opportunities for staff to engage in abuse. Confidential statement further revealed recantation of abuse to assigned social worker on 3/03/2025 but reaffirmed alleged abuse to others since leaving placement. Records reviewed found no indication of any trauma during C1's forensic examination. Confidential interviews with staffs and resident further denied the allegation, denied witnessing or other residents being subjected to sexual abuse. Information obtained found that C1 maintains that S1 threatened C1 with a gun to instill fear to sodomize C1. Interviews found that staff members denied there are firearms on the property, and witnesses also denied observing S1 handling a firearm at the facility. Information from interviews found that C1 maintains that S1 gave C1 marijuana on several occasions. Facility staff members reported that C1 sometimes asked for marijuana, but witness statements maintain denial of giving C1 any marijuana or that C1 smoked at the facility. Statements determined denial and no witness observations of S1 smoking at the facility. Based on gathered information, the allegations that S1 sexually abused C1; S1 threatened C1 with a gun and S1 provided marijuana to C1 is therefore determined unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. There are no deficiencies cited per California Code of Regulations, Title 22, at this time. A copy of this report is provided to Administrator by email.

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

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

met_with: Shamecka Powell, DSP


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Investigation Findings:
13On 07/10/2025 at 1:50PM Licensing Program Analyst (LPA) Justine Armstrong and Licensing Program Analyst (LPA) Aimee Mortatalla arrived at Dream Home Residential for the purpose of delivering findings for the allegation(s) 1.Staff hit minor in care 2. Staff injured minor in care. Supervision. LPA met with Leah Hawkins at the facility Administrator. A Health and safety risk assessment was conducted upon arrival. During the investigation, the LPA conducted confidential interviews with various staff members and reviewed a range of documents, including the detailed Unusual Incident Report. Throughout these interviews, staff members denied the allegations. The LPA determined that while the statements posed some concerns, they lacked sufficient evidence or testimony. Although the incident may have occurred or be valid, there was not a preponderance of evidence to prove that the alleged violation took place. The Department has decided that the allegations are Unsubstantiated; however, if any additional information is received, this complaint can be amended, and the finding can be changed. No deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Enrique M Hernandez LICENSING EVALUATOR NAME: Justine Armstrong 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 1

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

met_with: Leah Hawkins


facility_name: DYER GROUP HOME

summary: Facility Evaluation

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Narrative:
On September 27, 2021 at 12:30pm Licensing Program Analyst (LPA) Donald Martin arrive at the above facility for the purpose of conducting an unannounced Annual Inspection. LPA Was greeted by House Manager, Rosie Marie Mexicano (HM) and allowed into the facility. LPA conducted a tour of the facility inside and out. There are four (4) non verbal children residing in the home. Home is set up as follows: Bedroom #1 has a single bed with one client. The room is equip with a dresser and a closet with sufficient clothing space. Bedroom #2 has two beds two dressers and closet space for two clients clothing. Staff #1 resides in Bedroom #3. Bedroom #4 has no residents and is used by Staff #1 as a personal game room. Bedroom 5 has a full bed and sleeps 1 client. The room is equip with a bed, dresser, and ample closet space for the client. Master suite is for house Manager Rosie Marie Mexicano which has an attached bathroom. (HM) reported there are no fire arms or weapons in the home. There is an in-ground pool on premises with a wooden fence. Fencing has a self latching gate that opens outward with latch at the top. Gate is kept locked when the pool is not in use and per Manager children are supervised at all times when in or around the pool by staff members. NOTE: The gate to the pool locks from the inside. HM stated that per Regional Center, the pool must be locked when housing Regional Center clients. LPA will follow up with Regional Center on this matter. The facility is clean, safe, sanitary, and in good repair. There was a broken faucet in bathroom #1. There was a Plummer at the facility when LPA arrived addressing the issue. Disinfectants/poisons and other hazardous items are inaccessible, they are kept locked in the Laundry Room. There is an adequate food supply (4 days perishable and at least 10 days non-perishable). Nutritious snacks are served between meals. Medication is locked in a cabinet located in the kitchen. LPA advised HM to double lock the medication. LPA also advised HM to have a locked refrigerator for possible medication that needs to be chilled. The Children's Personal Rights is posted, upheld and Staff have been instructed to report Personal Rights Violations. Cont 809-C Two client filed were reviewed. There were no missing items in the files of Child #1 or Child #2. Clients Physicals and Dental exams were outdated due to Covid-19. HM stated that all clients are scheduled to have their exams in October 2021. HM will notify LPA when exams are completed. The vehicle is a Cadillac Escalade. The vehicle is in good working condition and the registration and insurance is up to date. There was plenty of extra towels and linen for the clients use. Two Staff files were reviewed. All required documentation was current and in the files. There are no excluded persons on premises and All adults working in the home have Criminal Clearances. Facility has a current Plan of Operation and HM has been instructed to report changes in the plan of operation which affects clients. HM has been reminded to report client injuries requiring medical treatment and other special incidents. There were no deficiencies cited at the time of the visit.

met_with: Rosie Mexicano-House Manager


summary: Facility Evaluation

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Narrative:
On October 14, 2022 at 10:00am Licensing Program Analyst (LPA) Donald Martin arrive at the above facility for the purpose of conducting an unannounced Annual Inspection. LPA Was greeted by House Manager, RosieMarie Mexicano (HM) and allowed into the facility. LPA conducted a tour of the facility inside and out. There are four (4) non verbal children residing in the home. Home is set up as follows: Bedroom #1 has a single bed with one client. The room is equip with a dresser and a closet with sufficient clothing space. Bedroom #2 has two beds two dressers and closet space for two clients clothing. Staff #1 resides in Bedroom #3. Bedroom #4 has no residents and is used by Staff #1 as a personal game room. Bedroom 5 has a full bed and sleeps 1 client. The room is equip with a bed, dresser, and ample closet space for the client. Master suite is for house Manager Rosie Marie Mexicano which has an attached bathroom. (HM) reported there are no fire arms or weapons in the home. There is an in-ground pool on premises with a wooden fence. Fencing has a self latching gate that opens outward with latch at the top. Gate is kept locked when the pool is not in use and per Manager children are supervised at all times when in or around the pool by staff members. NOTE: The gate to the pool is kept locked when not in use. HM stated that per Regional Center, the pool must be locked when housing Regional Center clients. The facility is clean, safe, sanitary, and in good repair. Disinfectants/poisons and other hazardous items are inaccessible, they are kept locked in the Laundry Room. There is an adequate food supply (4 days perishable and at least 10 days non-perishable). Nutritious snacks are served between meals. Medication is locked in a cabinet located in the kitchen. The Children's Personal Rights is posted, upheld and Staff have been instructed to report Personal Rights Violations. The vehicle is a Cadillac Escalade. The vehicle is in good working condition and the registration and insurance is up to date. There was plenty of extra towels and linen for the clients use. Cont 809-C The garage was used for storage and also had a weight set. The garage stays locked and is inaccessible to clients. Two client filed were reviewed. Clients Physicals and Dental exams were up to date. Two Staff files were reviewed. All required documentation was current and in the files. Staff interviews were conducted. No Client interviews were conducted because the clients are Non-Verbal. There are no excluded persons on premises and All adults working in the home have Criminal Clearances. Facility has a current Plan of Operation and HM has been instructed to report changes in the plan of operation which affects clients. There were no deficiencies cited at the time of the visit.


summary: Facility Evaluation

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Narrative:
On July 30, 2024 at 9:30am Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of conducting an Annual/Random inspection. LPA was met by House Manager, Rosie Mexicano (S1) and allowed into the facility. The facility capacity is 4 ambulatory, developmentally disabled clients. The house layout is as follows: Bedroom #1 has a single bed. The room is for one client. The room is equip with a dresser and a closet with sufficient clothing space. Bedroom #2 has two beds two dressers and closet space for two clients clothing. Bedroom # Has one queen bed with a dresser and closet space for clothing. Bedroom #4 is a separation room which has a bed, dresser and closet space. Bedroom 5 is currently empty. LPA was informed that the room is being converted to the house office. Master suite is for house Manager Rosie Marie Mexicano which has an attached bathroom. (S1) reported there are no fire arms or weapons in the home. There are two bathroom located in the hallway next to the bedrooms. Both bathrooms are clean and in good working condition. There is an in-ground pool on premises with a white fence surrounding it. Fencing has a self latching gate that opens outward with latch at the top. Gate is kept locked when the pool is not in use and per Manager children are supervised at all times when in or around the pool by staff members. NOTE: The gate to the pool is kept locked when not in use. HM stated that per Regional Center, the pool must be locked when housing Regional Center clients. The water shut off valve is on the side of the home in the backyard. the Electric shut off is on the opposite side of the home in the front. The facility is clean, safe, sanitary, and in good repair. Disinfectants/poisons and other hazardous items are inaccessible, they are kept locked in the Laundry Room. There is an adequate food supply (4 days perishable and at least 10 days non-perishable). Nutritious snacks are served between meals. Cont 809-C There was plenty of perishable and non perishable food accessible to the clients and a menu posted on the refrigerator. Medication is locked in a cabinet located in the kitchen. The living room has three couches and a TV on the wall. The Children's Personal Rights is posted, upheld and Staff have been instructed to report Personal Rights Violations. The vehicle is a Cadillac Escalade. The vehicle is in good working condition and the registration and insurance is up to date. There was plenty of extra towels and linen for the clients use. The garage stays locked and is inaccessible to clients. Two client files were reviewed. Clients Physicals and Dental exams were up to date. Three Staff files were reviewed. All required documentation was current and in the files. Staff interviews were conducted. No Client interviews were conducted because the client is Non-Verbal. There are no excluded persons on premises and All adults working in the home have Criminal Clearances. Facility has a current Plan of Operation and HM has been instructed to report changes in the plan of operation which affects clients. There were no deficiencies cited at the time of the visit.


summary: Facility Evaluation

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Narrative:
On January 29, 2026 at 2:30pm Licensing Program Analyst (LPA) Donald Martin arrived at the above facility for the purpose of changing the "Type of visit" to Annual/Required from the Annual/Random inspection I previously conducted on July 30, 2024 at 9:30am. LPA was met by House Manager, Rosie Mexicano (S1) and allowed into the facility. The facility capacity is 4 ambulatory, developmentally disabled clients. The house layout is as follows: Bedroom #1 has a single bed. The room is for one client. The room is equip with a dresser and a closet with sufficient clothing space. Bedroom #2 has two beds two dressers and closet space for two clients clothing. Bedroom # Has one queen bed with a dresser and closet space for clothing. Bedroom #4 is a separation room which has a bed, dresser and closet space. Bedroom 5 is currently empty. LPA was informed that the room is being converted to the house office. Master suite is for house Manager Rosie Marie Mexicano which has an attached bathroom. (S1) reported there are no fire arms or weapons in the home. There are two bathroom located in the hallway next to the bedrooms. Both bathrooms are clean and in good working condition. There is an in-ground pool on premises with a white fence surrounding it. Fencing has a self latching gate that opens outward with latch at the top. Gate is kept locked when the pool is not in use and per Manager children are supervised at all times when in or around the pool by staff members. Cont 809-C NOTE: The gate to the pool is kept locked when not in use. HM stated that per Regional Center, the pool must be locked when housing Regional Center clients. The water shut off valve is on the side of the home in the backyard. the Electric shut off is on the opposite side of the home in the front. The facility is clean, safe, sanitary, and in good repair. Disinfectants/poisons and other hazardous items are inaccessible, they are kept locked in the Laundry Room. There is an adequate food supply (4 days perishable and at least 10 days non-perishable). Nutritious snacks are served between meals. There was plenty of perishable and non perishable food accessible to the clients and a menu posted on the refrigerator. Medication is locked in a cabinet located in the kitchen. The living room has three couches and a TV on the wall. The Children's Personal Rights is posted, upheld and Staff have been instructed to report Personal Rights Violations. The vehicle is a Cadillac Escalade. The vehicle is in good working condition and the registration and insurance is up to date. There was plenty of extra towels and linen for the clients use. The garage stays locked and is inaccessible to clients. Two client files were reviewed. Clients Physicals and Dental exams were up to date. Three Staff files were reviewed. All required documentation was current and in the files. Staff interviews were conducted. No Client interviews were conducted because the client is Non-Verbal. There are no excluded persons on premises and All adults working in the home have Criminal Clearances. Facility has a current Plan of Operation and HM has been instructed to report changes in the plan of operation which affects clients. There were no deficiencies cited at the time of the visit.


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Narrative:
Although the allegation may have happened or is valid, based on LPA's observations and interviews, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was provided to Administrator Alyssa Kianidehkian, whose signature on this form confirms receipt.

Investigation Findings:
13This an amended report, original report date of 04/26/ LPA amended report due to making the report Public. On 04/26/24 at 10:45AM, Licensing Program Analyst (LPA) Celeste Aparicio made an unannounced visit to the above facility and met with Administrator, Alyssa Kianidehkian for the purpose of delivering findings for a complaint investigation. The Department received a complaint alleging that facility staff inappropriately touch minor while in care. Part of this investigation was investigated by the Investigations Bureau of the Community Care Licensing Division. LPA reviewed incident reports, the client file, and conducted confidential interviews. After the review of documentation and interviews with relevant parties, it was found that the allegation could not be corroborated due to inconsistent statements obtained. Report continued LIC9099-C... UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Celeste Aparicio 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 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE FACILITY NAME: EDGEWOOD CENTER FOR CHILDREN AND FAMILIESFACILITY NUMBER: VISIT DATE: 04/26/2024

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

met_with: Alyssa Kianidehkian


facility_name: EDGEWOOD CENTER FOR CHILDREN AND FAMILIES

summary: Facility Evaluation

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Narrative:
On December 22, 2022 at 9:30am, Licensing Program Analyst (LPA) Monica Pavia conducted an announced pre-licensing inspection of the facility. LPA met and toured the facility with America Grajeda and Augustine Arballo Jr. This facility is transitioning from a Short-Term Residential Therapeutic Program to a Group Home. There are several buildings on the property. The Stow Cottage is utilized as the residential cottage, with a capacity of 12. The Stow Cottage consists of 6 client bedrooms and several client bathrooms, living and dining areas, kitchen, laundry, recreation room and many other rooms for client use. The facility is clean, safe, sanitary, and in good repair. All passageways are unobstructed and all doors open freely. There is no pool on the facility premises. Fire arms are not allowed on the facility premises. At the time of visit, the following was observed: Fire extinguishers are throughout the house. Smoke detectors are throughout the house and operational. Carbon monoxide detectors are located in the hallway. Each bedroom has a bed, clean linens, and adequate drawer/cabinet space. Facility has a fire clearance. First aid kit was observed. Hot water temperature measured at 118 degrees Fahrenheit. Staff records are kept in the Administration building, on the property. Client files are locked in the chart room, in Dimond Cottage. Medications are centrally stored and locked. Disinfectants and other toxic materials are locked. Hygiene products are locked in the hallway closet. Extra bedding and towels are in the hallway closet. Knives and sharps are kept locked in the kitchen. This facility has been approved for licensure as a Group Home with a capacity of 12, as of today, December 22, 2022. LPA Pavia will email a copy of your license.

met_with: America Grajeda


summary: Facility Evaluation

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Narrative:
On 3/22/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a post-licensing inspection. LPA met with Administrator Alyssa Kianidehkian and informed of the purpose of the visit. The CARE Inspection Tool was used to complete this inspection. LPA conducted a tour of two cottages, the main residential cottage, Stow, and a secondary cottage, Halleck. Administrator informed LPA yesterday that a tree fell on Stow that afternoon and the residents were moved to Halleck. No residents were in Stow when the tree fell, and the licensee is working on making repairs to the roof. Both cottages were clean, and food and the residents' belongings have been brought over to Halleck. Kitchen and bathrooms were sanitary, and activity space was organized and free of obstructions. LPA conducted interviews with 3 residents and 3 staff and reviewed 5 resident files and 5 personnel files. Files were observed to be complete, and no concerns were identified in interviews. The following deficiency was found: Hot water in the resident bathrooms measured above the permitted range (above F). LPA is issuing a citation of California Code of Regulations, Title 22, Section 80088(e)(2). See attached LIC 809-D. An exit interview was conducted, appeal rights provided, and a copy of this report was left with Administrator Alyssa Kianidehkian, whose signature on this form confirms receipt.

met_with: Administrator Alyssa Kianidehkian


summary: Facility Evaluation

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Narrative:
An unannounced annual inspection was conducted by Licensing Program Analyst (LPA), Celeste Aparicio on 12/12/23 at 10:25AM. LPA met with Administrator Alyssa Kianidehkian and inspected the facility, inside and out. LPA reviewed four client files, disaster preparedness protocol, and reviewed physical plant. All client files appeared complete with signatures of admission agreements and consent forms.Centrally stored medications are maintained in a locked cabinet. Sharps and Toxic chemicals are kept locked. The facility has a written emergency disaster plan. All facility smoke and carbon monoxide detectors appear to be in appropriate working order and water temperature in facility measured within range. There is at least one-week supply of nonperishable and a two-day supply of perishable foods. Facility has extra keys for vehicles in case or emergency and are accessible by multiple staff. Facility has 1 waivers for more than two clients per bedroom and are meeting the terms and conditions. One Technical Violations and two Technical Advisories were issued, LPA discussed them with Administrator. At this time the inspection is not complete, LPA will return to complete the inspection. No deficiencies were cited at this time. LPA conducted an exit interview with Alyssa Kianidehkian, Administrator, at 4: PM. A copy of this report was provided at the completion of this inspection.

met_with: ALYSSA KIANIDEHKIAN


summary: Facility Evaluation

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Narrative:
An unannounced annual inspection continuation visit was conducted by Licensing Program Analyst (LPA), Celeste Aparicio on 12/13/23 at 10:45AM. LPA met with Administrator, Alyssa Kianidehkian, to finish the annual inspection. LPA met with Human Resources Personnel, who provided five staff files for LPA to review. All personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Personnel Files are maintained on-site and electronically. LPA reviewed Emergency Intervention Plan and discussed with Administrator about the types of manual restraints utilized by the facility and under what circumstances. All staff have received appropriate training in accordance with facility program statement. LPA conducted three client interviews and review the facility's operations. No deficiencies were observed or cited at this time. LPA conducted an exit interview with Administrator, Alyssa Kianidehkian, at 4:20PM. A copy of this report was provided at the completion of this inspection.


summary: Facility Evaluation

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Narrative:
On 4/15/25, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management inspection in order to follow up on a submitted incident report. LPA met with Administrator Alyssa Kianidehkian and informed of the purpose of the visit. Based on the submitted incident report, there was an alleged altercation between a staff member and a client. The involved client is no longer in care, and the involved staff member is not on site today. LPA discussed the incident details with Administrator. LPA requested that a copy of the internal review be sent to LPA by Friday 4/18/25. No deficiencies have been observed, and no citations are being issued at this time. An exit interview was conducted, and a copy of this report and the licensee's appeal rights were provided to Administrator.


summary: Facility Evaluation

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Narrative:
On 5/23/25, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management inspection in order to follow up on a submitted incident report. A prior visit regarding the same incident was made on 4/15/25. LPA met with Administrator Alyssa Kianidehkian and informed of the purpose of the visit. Based on the submitted incident report, an allegation was made of inappropriate conduct by a staff member during an interaction with a client. Based on confidential interviews and record review, the allegation could not be proven to have occurred and the initial reporting party recanted the allegation. No deficiencies were found. An exit interview was conducted, and a copy of this report and the licensee's appeal rights were provided to Administrator.


summary: Facility Evaluation

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Narrative:
On 9/18/25, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit in order to follow-up on two incident reports. LPA met with Administrator Alyssa Kianidehkian and informed of the purpose of the visit. Per the incident reports, in two separate incidents involving one client each, clients ran away from the facility and were assessed by police. The clients are no longer in care, and it was determined that they require a higher level of care. Administrator provided LPA an overview of the events, the facility's response, and the facility's referral and re-referral process. No deficiencies were observed, and a copy of this report was provided to Administrator.


summary: Facility Evaluation

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Narrative:
On May 5, 2026, at 10:30 a.m., Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced case management inspection at the above-referenced facility to follow up on an Incident Report (IR) submitted by the facility. LPA Medina met with Alyssa Kianidehkian, Administrator who also assisted with the walk through of the facility. During the inspection, LPA Medina interviewed Administrator regarding an incident that occurred. According to the Incident Report, a client made an allegation about a staff member at the program. Due to the severity of the allegation staff interviewed client, made a CPS report, and notified all required agencies. Staff heard the allegations from a phone call client had with a family member. Client denied making any allegations that the staff member heard and said it was a misunderstanding. On todays visit LPA Medina conducted a follow-up investigative interview to determine whether it was just a misunderstanding. Upon review of facility record and confidential interview LPA determined that it was a misunderstanding and facility followed proper protocols by doing an internal investigation, notifying the department, and CPS to make sure the serious allegation was properly followed up on. LPA received a copy of the internal investigation document and staff contacts on todays visit. Due to there being insufficient information by client no CPS did not take the report because client said nothing happened. At the time of visit client had been discharged to higher level of care. No deficiencies were observed. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Alyssa Kianidehkian, Administrator . Signature on this report acknowledges receipt.

met_with: Alyssa Kianidehkian - Administrator


facility_name: EGI TREATMENT - QUAIL OAKS

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Narrative:
Minors are not allowed hygiene items Confidential interviews revealed conflicting statements regarding whether clients are not allowed hygiene items. Interview information revealed that clients are given hygiene boxes that contain toothbrush, toothpaste, soap, shampoo, conditioner, deodorant, lotion, and other products which are available when the clients request them. Confidential interviews stated that clients are provided razors to shave but under the supervision of staff. It was noted in the facility's program statement that staff can withhold hygiene items from clients and provide them upon the request of the client depending on the client's level. Staff open minors' personal mail Confidential interviews indicated that the therapist keep all mail, unopened until the clients' next one-on-one therapy sessions. It was also disclosed that clients are required to open their letters in front of staff to make sure there is no contraband and confirmed that staff do not open clients' mails. Other confidential witnesses were unaware of the mail process and could not speak to this allegation. Some confidential witnesses stated that the clients open their personal mail in front of staff, and others stated the clients' primary therapists open their mail for them to screen letters and packages for contraband or triggering content. Minors not receiving an allowance Confidential interviews revealed that none of the minors received allowance during their residency at this Group Home. Per Facility Representative(s), the purpose of not providing clients allowance was to reduce the ability of incoming contraband. Facility Representative(s) also indicated that clients did not have a need for allowance as the Program provide the necessities for clients. Confidential interviews revealed that although allowance is not given, the facility provide for clients' needs which includes items while on outings. Minors are denied access to personal property Confidential interviews revealed that clients are denied personal property based on scheduled activities and for their safety. Some personal items are stored locked in a cabinet and made available to clients upon request. Per Facility Representative(s) some items such as razors require direct supervision, while other personal items (such as books, clothing and etc.) are not allowed to be possessed by clients because the item could trigger client's behaviors or jeopardize their safety while in treatment Continue on LIC9099-C Based on the confidential interviews, observation, and record review, it has been determined that although the allegations that minors are not treated with dignity; minors are not allowed hygiene items; staff open minors' personal mail, minors not receiving an allowance, and minors being denied access to personal belongings may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. The program statement has been updated to ensure that the clients' needs will be met based on their individual assessments per Title Group Home Regulations. An exit interview was conducted, appeal rights discussed, and a copy of this report was provided to Facility manager.

Investigation Findings:
13On November 29, 2021, Licensing Program Analyst (LPA) Enrique Hernandez arrived at the facility to deliver the findings of a complaint investigation. LPA Hernandez met with Danielle Castro and discussed the investigative findings. On June 7, 2021, the Department received a complaint alleging minors are not treated with dignity; minors are not allowed hygiene items; staff open minors' personal mail; minors are not receiving an allowance; minors are being denied access to personal property. Confidential interviews were conducted with 6 staff and 2 of 2 clients. Facility's Program Statement, Plan of Operation, Parent Handbook and Training Manual were reviewed. The following information was obtained during the course of the investigation: Minors are not treated with dignity Confidential interviews revealed conflicting statements that clients must leave the bathroom door ajar while using the restroom. Some confidential interviews reported that the clients did not have to leave the door open while using the restroom and other interviews stated that clients must leave the bathroom door ajar while using the restroom. It was noted in the facility's program statement that staff are to ensure that the clients keep the bathroom door ajar when using the restroom. Continue on LIC9099-C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Enrique M Hernandez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: EGI TREATMENT - QUAIL OAKSFACILITY NUMBER: VISIT DATE: 11/29/2021

met_with: Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On November 16, 2021 at 1:45pm, Licensing Program Analyst (LPA), Enrique Hernandez conducted an unannounced inspection, at the above-said facility, for the purpose of conducting an Annual Required Inspection. LPA Hernandez met with Daniela Castro Facility Manager (FM) who granted access into the facility and provided a tour of the entire facility, inside and out. This facility is designed to accept privately placed children and will be licensed to provide care and supervision for six (6) ambulatory only clients, ages 12-17 years. This is a one-story house with three bedrooms, four and a half (4.5) bathrooms, school room, kitchen, dining room, group room, laundry room, medication closet, three (3) therapy rooms, two (2) staff offices, yoga room, converted garage, outdoor seating areas, barbecue area, and gated pool. There is a vehicle available to transport consumers/clients Toyota Sienna and the current auto insurance is with ACE American Insurance Company LPA observed the following during inspection: Bedroom #1: Is occupied by Client #1 (C1) and Client #2 (C2). The room is equipped with two (2) twin size beds. There are adequate drawers, closet space, and lighting in the room. Bedroom #2: Is occupied by Client #3 (C3) and Client #4 (C4). The room is equipped with two (2) twin size beds. There are adequate drawers, closet space, and lighting in the room. Bedroom #3: Is occupied by C#5 (C5). The room is equipped with two (2) twin size beds. There are adequate drawers, closet space, and lighting in the room. Bathrooms: The facility has a total of four and a half bathrooms. Bathroom #1: Is the half bathroom located to the left next to the cleaning supplies closet. Bathroom #2: Is located next to Bedroom #2. Bathroom #3: Is located next to office Room #2. Bathroom #4: Is located adjacent to the laundry room. Bathroom #5: Is located inside the yoga room outside which is only used by the facility staff. LPA observed during the inspection one bathroom by the hallway was unlocked Page 1 of School Room: Is located to the right once entering the facility. There is ample seating space with chairs, desks, computers, and a covered fire place. FM stated that doesn't have gas. LPA observed the carpet worn Dining Room: Is located next to the School Room. There is one table with nine (9) chairs. Group Room: Is located next to the kitchen. There are ample seating space and a covered fire place. There is also a door that exits out into the yard. Kitchen: There is a stove with four (4) burners and a center grill all working at this time. There is a detached oven currently working at this time. There is a microwave and refrigerator/freezer. The food service in the home is adequate with perishable/nonperishable food supplies. The cleaning solutions are made inaccessible to the clients and stored/locked under the kitchen sink and in hallway closet. All trash cans have a tight lid on. There is also a dining area located to the side of the kitchen. Medication Closet: Is located next to the Laundry Room. This space is used to store and administer client medications. The medication closet is kept locked and only accessible to staff supervising stored medications. Laundry Room: Is next to the Medication Closet. There is a washer and dryer available. The detergent is kept locked in a cabinet inside the Laundry Room. Therapy Rooms: One of the three therapy rooms is located next to the kitchen. The second therapy room is located outside in a converted shed. Therapy room #3 is located out in the backyard next to the yoga room. Yoga Room: Is located out in the backyard. This room is used to do yoga, boxing and de-escalating clients. Outdoors: The entrance and backyard are all free of debris and hazardous materials. There is a barbecue area with operating burners. LPA Hernandez. also observed two outdoor seating areas available for clients to use. There is also a swimming pool on the premises with a five foot fence with a self-latching lock. Overall, the home appears to be clean, safe, sanitary, and in good repair. LPA Hernandez. observed non-perishable foods for one week and perishable foods for two days. The home has a first aid kit stored inside a cabinet in the laundry room. Page 2 of The facility has a total of five (6) fire extinguishers. One is mounted onto the wall at the entrance. Second fire extinguisher is located by the Bedroom area mounted onto the wall. Third fire extinguisher is located in the kitchen. Fourth fire extinguisher is located inside the laundry room. The fifth fire extinguisher is located inside staff office #2. Staff Office #2 is located outdoor next to the converted garage which is used as a gym. Staff #1 is office located inside the facility next to bedroom #3. All fire extinguishers were fully charged. Disinfectants and poisons are inaccessible to the clients in care they are kept locked at all times. All knives and sharp objects are made inaccessible to the clients in care locked in a security box inside a locked kitchen cabinet. All smoke detectors and carbon monoxide are operable. There is a working telephone line available for clients to use. The following was discussed with the facility Administrator: Children will be accorded personal rights. Children in care will be supported, encouraged to participate in extracurricular activities. Children in care will be able to contact the licensing agency. All posting requirements were met. The home will operate within capacity and limitations of license. there is camera waiver on file but is under review Per California Code of Regulations, Title Regulations, Division 6, Chapters 1 & 5, the following deficiencies have been cited. (See LIC809-D) Due to time constraints, LPA shall return to complete the Annual Required Inspection. Exit interview was conducted and Plans of Corrections were reviewed and developed with the Facility Manager. A copy of this report and appeal rights were discussed and left with the Lead Staff CeCi Perez due to that the Facility Manager had to leave the facility. Page 3 of 3