facility_name: JORDAN HOUSE OF UMOJA

raw_content:
Investigation Findings:
13On 4/24/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a complaint investigation visit. LPA met with Executive Assistant Betheny Jordan and informed of the purpose of the visit. Based on confidential observations, interviews, and record review, the investigation found that the facility agreed to provide transportation to a medical appointment scheduled by the authorized representative, who holds medical rights. The facility was not provided sufficient notice of the initial appointment to arrange transportation. The day of the rescheduled appointment, the assigned staff member had a personal emergency and could not provide transportation. The appointment was rescheduled, and the resident has since been assessed. Although the allegations may have happened or are valid, based on LPA's observations and interviews, there is not a preponderance of the evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. An exit interview was conducted, appeal rights provided, and a copy of this report left with Executive Assistant. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Mariah Hawkins 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: Executive Assistant Betheny Jordan


state: CA

summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13On 4/24/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a complaint investigation visit. LPA met with Executive Assistant Betheny Jordan and informed of the purpose of the visit. Based on confidential observations, interviews, and record review, the investigation found that the facility restricted family visitation and phone calls without the support of the full care team. Upon learning that an authorized representative did not agree with the new plan, the facility did not revise the plan. The plan of operation was then revised to support the revised visitation/call plan, including a statement that the licensee has deciding power to make such changes. The preponderance of evidence standard has been met, and therefore the above allegations is found to be substantiated. LPA is issuing citations of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section Personal Rights. An exit interview was conducted, appeal rights provided, and a copy of this report left with Executive Assistant Betheny Jordan. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Mariah Hawkins 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: JORDAN HOUSE OF UMOJAFACILITY NUMBER: 075650172

report_type: Complaint Investigation

complaint_status: unsubstantiated


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
The preponderance of evidence standard has been met, and therefore the above allegation is found to be substantiated. 1 deficiency citation was issued at today's visit. See attached deficiency page. A plan of correction for the deficiency was developed in consultation with an authorized facility representative. LPA conducted an exit interview and reviewed this report and attachments with Administrator. Copies of this report, attachments, and appeal rights were provided at the end of the visit.

Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

met_with: Administrator George Jordan, Facility Manager Nathan Austin

complaint_status: SUBSTANTIATED


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Additionally, it was found that not all staff were ensuring they had a resident's rescue inhaler during transport, due to not bringing it in the vehicle and not being able to locate it in the vehicle. Administrator and staff confirmed that the inhaler was stored in the console of the vehicle. Staff were ensuring they had the inhaler during afternoon activities but not during morning transport to school, which is located about 40 minutes away from the facility. 2 deficiency citations were issued at today's visit. See attached deficiency page. A plan of correction for each deficiency was developed in consultation with an authorized facility representative. LPA conducted an exit interview and reviewed this report and attachments with Facility Manager. Copies of this report, attachments, and appeal rights were provided at the end of the visit.

Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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

met_with: Administrator George Jordan; Facility Manager Nathan Austin


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

met_with: Malik Petri


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:


summary: Complaint Investigation - Substantiated

met_with: Supervising Facility Manager Lanesha Morris

investigation_findings: SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
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: Facility Manager, Lanesha Morris


raw_content:
Narrative:
Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted, appeal rights were provided, and a copy of this report was left with the Supervising Facility Manager.

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: Supervising Facility Manager, Lanesha Morris


summary: Facility Evaluation

raw_content:
Narrative:
On December 21, Licensing Program Analyst (LPA) Monica Pavia met with applicant/Administrator, George Jordan, for a prelicensing inspection. LPA discussed the following: Forms that the facility uses and will continue to use. Corporate organization - Including chain of command and roles of staff Written plans, policies or procedures that was submitted with the application. Administrator/Director qualifications and duties. 1. Facility grounds inspected. Grounds are clean and free from observable hazard. Clear passageways throughout the facility. The facility does not have a swimming pool or any bodies of water. Firearms are not allowed on facility premises. 2. Adequate indoor activity space and materials observed, and outdoor activity space was observed. 3. Sharps and cleaning supplies are locked in a filing cabinet, locked in the staff office. 4. Procedures for locked and centrally stored medications observed. 6. Adequate storage space observed. 7. Individual beds in good repair observed. A supply of extra linens available for bed changes. 8. The house is one story and has 3 client bedrooms. Bedrooms are accommodating of all required furnishings. 9. Adequate food storage space observed. Facility will add appropriate supply of required foods and emergency foods upon placement of youth in the home. 10. Sample menu posted. 11. All appropriate forms posted within client view. 12. Dining room equipped with large table and chairs accommodating of all clients. 13. Facility has 2 restrooms for client use, all are operable. 14. Facility will get additional cutlery, bowls and cups, prior to client placement. (Email picture of items in cupboard.) 15. Client files will be kept in a locked filing cabinet, locked in the staff office. 16. Staff files will be kept locked at the facility main office, and will be available for review at facility, within a reasonable time frame of request by LPA. 17. Applicant will request a Narcan Waiver via email to LPA Pavia. (PIN 23-11-CRP emailed.) 18. Applicant was emailed the current Personal Rights (6/22) on this date, to post. 19. Once CCL has created and disbursed a Camera Waiver PIN, applicant will request camera waiver from assigned LPA in San Bruno. Facility already had two cameras installed, prior to LPA's inspection. One camera is located in front living area and one in the facility hallway. Cameras record 24 hours. Video automatically deletes after 7 days. Applicant is the only person who can access camera footage. 20. Applicant turned down hot water during LPA inspection. Applicant will measure hot water temperature within the next week, and take picture with thermometer under running water, and send via email to LPA Pavia. Applicant is associated through Guardian and has been fingerprint cleared. Prior to accepting placement's, all staff must be fingerprint cleared and associated to the facility. Discussed Guardian process with the facility. Discussed Incident reporting. An initial report for all reportable incidents is to be made by the next working day to sbircr@dss.ca.gov. A full report is to be remitted within 7 days and may also be made to the incident reporting email. After licensure, you will receive a letter notifying you of your assigned LPA, from the San Bruno office. The application will be given to Licensing Program Manager (LPM), Carolyn Flynn, for review. I will notify you once the SOC analyst has finished the review of your Plan of Operation/Program Statement, ILS, v5, submitted via email on November 30, 2023. Actionable items are in bold print. A copy of this report was provided to George Jordan.

report_type: Facility Evaluation

visit_type: Prelicensing

met_with: George Jordan


summary: Facility Evaluation

raw_content:
Narrative:
On 4/24/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a post-licensing inspection. LPA met with Administrator George Jordan and Human Resources Manager Betheny Jordan and informed of the purpose of the visit. LPA used the CARE Inspection Tool to complete this inspection. LPA toured the facility site and inspected facility records. LPA obtained resident school information and staff contacts as interviews were not conducted during the inspection. LPA also obtained a current LIC 500. LPA observed the facility to be maintained in safe condition, kitchen and bathrooms were in sanitary condition, resident bedrooms were furnished and offered clean linens and plenty of storage space, and potentially dangerous items, including chemicals, knives, and medications, were stored where inaccessible to the resident in care. LPA observed files to be complete. However, a continuation visit will be conducted to complete the file review. LPA observed an area where technical support may be beneficial. See the LIC 9102 advisory note linked to this report. No deficiency citations were issued at today's visit. As stated above, a continuation visit will be conducted. An exit interview was conducted, appeal rights discussed, and a copy of this report left with Human Resources Manager Betheny Jordan.

met_with: Administrator George Jordan; Human Resources Manager Betheny Jordan


summary: Facility Evaluation

raw_content:
Narrative:
On 5/1/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit to continue a post-licensing inspection. LPA met with Administrator George Jordan and Human Resources Manager Betheny Jordan. During today's inspection, LPA continued inspection of personnel files and other facility files and completed two staff interviews. No deficiencies were observed. Due to time constraints, LPA was unable to complete the review of staff training. Facility agreed to email LPA the training records for staff S1, S2, S3, S4, and S5. See LIC Confidential Names. The training records will include initial training, any additional and/or annual training, intervention and restraint training, and facility manager training. Facility agreed to submit these by 5/6/24. A continuation visit will be conducted to document the review of personnel training records and conduct remaining required interview(s). An exit interview was conducted, and a copy of this report was left with Administrator.

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On 5/15/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a visit to the facility to complete the post-licensing inspection. LPA met with Supervising Facility Manager Lanesha Morris and informed of the purpose of the visit. LPA interviewed one resident. Additionally, LPA agreed to receive personnel training records for LPA's review. LPA completed this review and observed records to be complete and staff to have met or surpassed the training requirements. The facility is in the process of reorganizing paper records and certificates maintained on site. No deficiencies were observed or cited at this visit. An exit interview was conducted, and a copy of this report was left with Supervising Facility Manager Lanesha Morris.


summary: Facility Evaluation

raw_content:
Narrative:
On 08/16/24, Licensing Program Analyst (LPA) Celeste Aparicio conducted a case management visit to follow-up on a submitted incident report. LPA met with Facility Youth Mentor and informed the Youth Mentor on the purpose of the visit. Based on the submitted incident report, a resident was searched by having staff check the resident's pockets after returning to the facility from a runaway. Facility Youth Mentor explained that staff conduct searches because of the resident potentially bringing contraband into the facility. LPA discussed the youths' personal rights regarding unreasonable searches and informed Youth Mentor that searches cannot be conducted as a part of facility policy. LPA provided technical support in the form of an advisory regarding the processes around case-by-case searches for residents in care. See LIC Technical Assistance. An exit interview was conducted, and a copy of this report was left with Youth Mentor, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 01/07/25, Licensing Program Analyst (LPA) Celeste Aparicio conducted a required annual inspection. LPA met with Facility Manager, Lanesha Morris and informed the Facility Manager on the purpose of the visit. LPA toured the facility site, reviewed three client files, interviewed one staff, and attempted one client interview. At the start of the inspection, all clients were at school. One client returned to the facility at the end of the inspection. The CARE Inspection Tool was used to conduct the inspection. LPA observed the facility to maintain individual client files. During the client file review, LPA identified two areas in which technical assistance may be beneficial. LPA is issuing technical assistance for California code of Regulations 80069(c)(1) and 80069(a). The facility is a one-story house in a residential neighborhood and has 3 single-occupancy bedrooms and one client bathroom. The facility and grounds are clean, tidy, and free of obstructions. LPA observed the facility food supply and observed the food to be of good quality, within date, and stored properly. LPA observed the hot water to measure within the permitted range. A continuation visit will be conducted to complete this inspection. An exit interview was conducted, and a copy of this report, were provided to Facility Manager Lanesha Morris, whose signature on this form confirms receipt.

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
On 01/14/25, Licensing Program Analyst (LPA) Celeste Aparicio conducted a case management visit to continue the annual inspection initiated on 01/07/25. LPA met with Facility Manager, Lanesha Morris and informed the Facility Manager on the purpose of the visit. During visit, LPA reviewed 6 personnel files, emergency intervention records, disaster preparedness records, and other operations-related records. During the inspection, two clients were present at the facility. LPA conducted two client interviews. The CARE Inspection Tool was used to complete the inspection. LPA identified three areas in which technical assistance may be beneficial. LPA is issuing technical assistance regarding complaint procedures and emergency intervention training curriculum addressing the techniques for returning the child to the planned activity following completion of the emergency intervention. The facility's Human Resources Department has agreed to send a copy of board minutes and emails to support the renewal process for the Administrator certification to LPA email by 01/14/25 4:59pm. An exit interview was conducted and a copy of this report was provided to Facility Manager Lanesha Morris, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 01/22/25, Licensing Program Analyst (LPA) Celeste Aparicio made an unannounced visit to the facility for the purpose of conducting a case management inspection in relation to the annual inspection conducted on 1/7/25 and 1/14/25. LPA met with Facility Manager, Lanesha Morris and informed the Facility Manager on the purpose of the visit. During the visit, LPA conducted two confidential interviews and toured the facility. The following was discussed and reviewed during the inspection: the facility visitation policy, facility incentives program, camera use within the facility, staff training, Mental Health services for the residents in care, and necessary updates to Needs and Services Plans. During the review of the visitation policy, LPA observed all clients to have signed the facility's visitation agreement. During the inspection, LPA advised that facility to edit their Program Statement to reflect the use of cameras within the facility and provided the Licensee with PIN 24-09CRP. LPA identified areas in which a Technical Assistances maybe beneficial. LPA issued a Technical Assistance for Plan of Operation 87022(e) and Trauma-Informed Interventions and Treatment Practices 87078.2(a)(3). See LIC9102. An exit interview was conducted and a copy of this report was provided to Facility Manager Lanesha Morris, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 05/06/25, Licensing Program Analyst (LPA) Celeste Aparicio made an unannounced visit to the facility for the purpose of conducting a case management. LPA met with Supervising Facility Manager, Lanesha Morris and informed the Supervising Facility Manager on the purpose of the visit. The purpose of the visit was to give notice of area(s) in which technical support may be beneficial. During a review of incident reports, LPA observed sections in the LIC LE incident report form to not be filled out. On a few reports, LPA observed the additional information section under the 'Type of Outcome' to be blank when the 'Other' box was checked. Additionally, LPA observed incident report narratives to be lacking detail on the incidents specified. LPA issuing a Technical Assistance for Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section 87061 (i)(2) and 87061 (j)(2)(E) Reporting Requirements. During the inspection, LPA also discussed the facility's upcoming Emergency Intervention Plan (EIP) Biannual Review. LPA will follow up with Supervising Facility Manager on the requirements for the biannual review. An exit interview was conducted, appeal rights were provided, and a copy of this report was left with the Supervising Facility Manager, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Celeste Aparicio made an unannounced visit to the facility to conduct the annual inspection. LPA met with Supervising Facility Manager, Lanesha Morris who facilitated the visit. LPA toured the entire home, inside and out. The home is set up as follows: This is a one- story home with three bedrooms, two bathrooms, a living room, a dining-room, staff office, and kitchen. Bedroom # 1 - occupied by minor ( single twin bed, one dresser and closet space, single standing lamp). Bedroom # 2 - occupied by minor (single twin bed, one dresser, and closet space, single standing lamp). Bedroom # 3 - occupied by minor (single twin bed, one dresser, and closet space, single standing lamp). Room #4 - occupied by staff used as a staff office/ therapy room. LPA conducted one staff interview and two client interviews. At the time of the inspection four staff and two clients present in the facility. During a tour of the home LPA observed in bedroom #1 occupied by C1 (See LIC811 attached), the bedroom ceiling to show significant water damage. There are irregular dark gray and black discolorations consistent with moisture intrusion and possible mold growth, along with yellow - brown straining. The ceiling surface appears textured, and in the corner there is peeling and cracking. Overall the ceiling depicts a compromised ceiling area likely caused by an active or prior leak, with visible damage. (See LIC809-C) Additionally, the LPA observed that the main freezer door located in the kitchen was broken, resulting in spoiled frozen food. No work order was available at the time of inspection. The LPA also detected an odor emanating from the facility's washing machine. During the inspection is was found that licensee does not provide clients in care with a locked container in which to store their contraceptives. Photos were taken of bedroom #1 and main freezer. LPA is issuing citation of STRTP Interim Licensing Standards (ILS) Section 87075(b)(1)(A)Health Related Services and California Code of Regulations (CCR) Section 80087(a)Buildings and Grounds. LPA is issuing four technical violations for the sections below (reference LIC9102 attached to report): 80069(c)(1) CCR Client Medical Assessment 87077(a)(2)(A) ILS Personal Services 87068.2(f) ILS Needs and Services Plan 87068.2(g) ILS Needs and Services Plan LPA is issuing six technical assistances for the sections below (reference LIC9102 attached to report): 87070(b)(1) ILS Children's Records 80076(a)(6) CCR Food Services 87077(a)(3) ILS Personal Services 87072(c) ILS Personal Rights 87070(b)(17) ILS Children's Records 87070(b)(18)(A) ILS Children's Records The annual inspection is not complete at this time. A continuation visit will be conducted at a later date to complete this inspection. An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to Supervising Facility Manager, Lanesha Morris whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 4/24/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit. LPA met with Administrator George Jordan and Executive Assistant Betheny Jordan and informed of the purpose of the visit. During an investigation at the facility, LPA became aware of deficiencies and areas in which technical support may be beneficial. Based on confidential observations, interviews, and record review, the licensee revised the plan of operation without providing to the licensing agency for review and approval prior to implementation. LPA is issuing a citation of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section Plan of Operation. Additionally, the licensee indicated in the revised plan of operation that per county, state, and team recommendations, the facility "holds sole responsibility" for visitation procedure changes. LPA advises that per the above cited ILS section, the facility must submit revised plan of operation procedures to the licensing agency for approval. LPA discussed that approval should be obtained prior to implementation. LPA also advised that individual visitation, transportation, and other service plans, and any modifications, be documented in the resident's needs and services plan and that, per ILS Section 87068. Modifications to the Needs and Services Plan, the facility ensure written approval of such modifications is obtained from the authorized representative(s) prior to implementation. Lastly, a transportation arrangement to a resident's medical appointment was made and when the assigned staff member could not provide transportation that day, an on-call staff member or other staff was not made available to ensure transportation. LPA advised that, per ILS Section Transportation, the facility is to ensure transportation to health related services, so to avoid missing future appointments, utilization of on-call staff is encouraged. An exit interview was conducted, appeal rights provided, and a copy of this report left with Executive Assistant Betheny Jordan.


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
On 06/10/24, Licensing Program Analysts (LPAs) Celeste Aparicio and Kristin Pierotti conducted a facility evaluation visit for a case management regarding an observed deficiency from a complaint investigation; control number 14-CR-20240506113008. LPA met with Facility Manager and informed on the purpose of the visit. During the investigation, confidential interviews and records review were conducted. Based on interviews, record review, and observation the following deficiency was discovered regarding background clearance for staff member S1. (See LIC811) LPA observed S1 to be working at the facility on 05/08/24. Upon LPA's arrival at the facility on 05/08/24, LPA observed S1 exiting the facility vehicle from the driver's seat. During records review conducted on 06/04/24, LPA observed the initials of an unknown staff member on the facility transportation log starting from 03/25/24 to 05/20/24. LPA also did not observe S1 on be on the LIC500. During a confidential interview, LPA learned S1 was still in training. Upon further review, LPA observed that S1's criminal background clearance with facility is in pending status. Therefore, S1 has been working at the facility since 03/25/24 without a criminal background clearance associated to the facility. LPA is issuing a citation of California Code of Regulations, Title 22, Division 6, Chapter 1, Article 3, Section Criminal Record Clearance, Subsection (e). Additionally, pursuant to Subsection (g) of this regulatory section, LPA is assessing an immediate civil penalty of one hundred dollars ($100) per violation (1) for a maximum of 5 days, for a total of five hundred dollars ($500). See attached LIC 809-D and LIC 421. An exit interview was conducted, appeal rights provided, and a copy of this report was provided to Facility Manager, whose signature on this form confirms receipt.

Deficiencies:
80019: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f)

met_with: Laneshe Morris

title:
1
2
3
4
5
6
780019 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


summary: Facility Evaluation

raw_content:
Narrative:
On Friday 9/6/24, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit regarding a deficiency observed during an investigation at the facility. LPA met with Supervising Facility Manager Lanesha Morris and informed of the purpose of the visit. Based on confidential observations, interviews, and record review, a staff member had a conversation with an individual unafilliated with the facility who is not a member of the care team or other agency working with the facility. During this conversation, confidential information about a resident in care was shared. LPA is issuing a citation of Short-Term Residential Therapeutic Program (STRTP) Interim Licensing Standards (ILS) Section Children's Records. See attached LIC 809-D. An exit interview was conducted, appeal rights were provided, and a copy of this report was left with Supervising Facility Manager.


facility_name: JOY HOUSE

summary: Facility Evaluation

raw_content:
Narrative:
On October 30, Licensing Program Analyst (LPA) Shikya Belfield met with Facility Administrator, Anjelle Skates for a pre-licensing inspection at the above facility. LPA discussed the following with Anjelle Skates: Forms that the facility uses and require updates. LPA observed LIC610C which needs to have updates made. LPA discussed roles and designation of responsibilities when administrator is absent- policies or procedures that was submitted with the application and discussed with LPA Monica Pavia during a pre-licensing inspection in June, the facility is changing location to this facility. 1. Facility grounds were inspected. There are three additional structures on facility grounds. Joy House will be utilized as the residential house for the Short-Term Residential Therapeutic Program (STRTP) license, capacity of 6. All buildings/structures on facility grounds, will be kept locked. Grounds are clean and free from observable hazards. The facility does not have a swimming pool or any bodies of water. Firearms are not allowed on facility premises. 2. Adequate indoor activity space was observed by LPA Belfield. Large outdoor activity space was observed By LPA Belfield.. 3. Storage for Chemicals and sharp objects such as knives, were observed and had appropriate locks.. 4. Procedures for Locked and centrally stored medications observed as well as a locked cabinet. 6. Adequate storage space observed in the facility. 7. Current activity schedule observed in the main hallway and living room. 8. Currently there are no activities supplies observed. 9. First aid kit observed. 10. Individual beds in good repair observed. A supply of extra linens available for bed changes. 11. Joy house has three client bedrooms, double occupancy and 3 client bathrooms. Bedrooms are accommodating of all required furnishings. 12. Adequate food storage space observed. Facility will add appropriate supply of foods upon placement of youth in the home. 13. Sample menu posted. 14. All appropriate forms posted within client view. 15. Dining room equipped with large table and chairs accommodating of all clients. 16. Hot water measured within the required temperature range 17. Fire place observed with cover however there is no locking mechanism to make inaccessible. Licensee agrees to place a lock over the fire place cover. Applicant and administrator are cleared through guardian and all staff hired will be criminally record cleared before being allowed to be in the facility. Discussed Incident reporting. An initial report for all reportable incidents is to be made by the next working day, either verbal or written. A full report is to be remitted within 7 days via email to SBIRCR@dss.ca.gov. Also discussed was any changes made to the administrative organization must be submitted to the department in writing within 10 days. All applications require a secondary review from a Licensing Program Manager (LPM). Once reviewed and approved by LPM, this STRTP facility will be ready for licensure. Licensee will complete component three of the licensing process before license is issued. All necessary changes needed will be sent to the department by the end of business on November 6, 2024. A copy of this report was left with Administrator Anjelle Skates.

met_with: Anjelle Skates


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Shikya Belfield and LPA Benjiman Oliver, conducted an unannounced inspection on 2/10/25 at 1: PM, and met with Program Coordinator Colleen Congress. Also present during this inspection were one staff and one clinician. The facility is licensed for a capacity of 6 ambulatory children, ages 12 -17. There are currently 1 client residing in the facility who was present during the time of this inspection. The CARE TOOL was used during this inspection. During this inspection LPA attempted to conduct an interview with client and was not successful. Due to time restrictions, the inspection could not be complete at this time. There were no violations cited during this inspection. An exit interview was conducted and copy of this report was left with Colleen Congress.

met_with: Colleen Congress


summary: Facility Evaluation

raw_content:
Narrative:
On 2-20-25 1:30PM, Licensing Program Analyst (LPA) George Karkazis conducted an unannounced inspection at Joy Hose, and met with Administrator Anjelle Skates, who helped with the inspection. The purpose of the inspection was to interview a client that may have witnessed an incident at their former placement. The client refused to interview. The facility was clean and in good order. An exit interview conducted and a copy of this report was given to Anjelle Skates, Administrator.

met_with: Anjelle Skates, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Shikya Belfield, conducted an unannounced inspection on 1/30/25 at 1: PM, and met with Administrator, Anjelle Skates. Also present during this inspection were one case manager, two staff, and one clinician. The facility is licensed for a capacity of 6 ambulatory children, ages 12 -17. There are currently 2 clients residing in the facility and only one client present during the time of this inspection. The CARE TOOL was used during this inspection. During this inspection, the entire facility was toured. The facility and grounds are in good repair, and free of obstructions. There is adequate indoor activity space and materials. Chemicals are stored in a locked cabinet. Locked and centrally stored medications observed. Adequate storage space observed. Individual beds are in good repair, clean mattresses and pillows observed. Bedrooms are accommodating of all required furnishings. Adequate food storage space observed. Supply of two days of perishable foods and nonperishable foods observed upon inspection. Weekly menu is posted in the kitchen. LPA Belfield reviewed one client file and no staff files. LPA conducted one client interview with C1 ( see lic811 dated 1/30/2025). All current residents were placed within the last 2 weeks. Fingerprint clearances were reviewed using Guardian on 1/30/2025. Based on a review of the facility roster printed on 1/30/25 and discussion with program administrator, one staff (S1) (See lic811 dated 1/30/2025), S1 is not criminally record cleared to work in this facility and they have worked at least five days in the last two weeks. Facility is being cited for violation of California Code of Regulations, Title 22, Divsion Six, Section 80019(e)(2) Criminal Record Clearance as described on the following page LIC9099D Civil penalty will be assessed. At this time the inspection is incomplete and will be completed at a later date. An exit interview was conducted and a copy of this report along with appeal rights were left with administrator Anjelle Skates.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Shikya Belfield and LPA Omar Sawyer, conducted an unannounced inspection on 4/25/25 at 11: AM, and met with youth advocate (staff) Irinea Duenas. Also present during this inspection were one client. The facility is licensed for a capacity of 6 ambulatory children, ages 12 -17. There is currently one client residing in the facility who was present during the time of this inspection. The CARE TOOL was used during this inspection. Licensee Helen Ayala arrived at the facility with Program Director Annahi Ruano, who continued the inspection with these LPA's. LPA's attempted to conduct an interview with the client however, the client declined to speak to these LPA's. LPA's conducted a walk through of the facility with staff and reviewed six staff files and three client files. Based on a review of staff files, six out of six files were missing information. Although staff received some training, they did not meet the requirements outlined in the regulations regarding CPR training and required training topics. Based on a review of client files, signed forms for policies and procedures were not present. Facility was cited for violation of California Code of Regulations Title Division Six or Interim Licensing Standards were during this inspection. Technical Advisories were issued regarding staff training. A review of the guardian system shows that all staff are criminally record cleared to work in the facility. An exit interview was conducted a copy of this report along with appeal rights was left with Licensee Helen Ayala.

met_with: Helen Ayala


summary: Facility Evaluation

raw_content:
Narrative:
On 08/28/2025 at 11:15 a.m., Licensing Program Analyst (LPA) Brenda Rodriguez conducted an unannounced Annual Inspection and met with Anjelle Skates, Administrator. LPA Rodriguez disclosed the purpose of the inspection and was granted entry into the facility by the Administrator. LPA Rodriguez used the CARE Inspection Tool. The facility currently has a census of two (2) clients. LPA Rodriguez reviewed five (5) staff files, two (2) client files, and the emergency disaster plan binder. LPA Rodriguez conducted two (2) confidential staff interviews and two (2) attempted confidential client interviews. The clients did not want to get interviewed. During physical plant inspection, no deficiencies were found. LPA Rodriguez toured the facility inside and out. All client bedrooms were equipped with comfortable furnishings which included ample storage space for clients' belongings and full-sized beds. Each bedroom has drawers for extra storage space. The client's bathroom was clean and furnished with hygiene supplies for each client. Extra linens are in a closet in the hallway. The facility is clean, safe, and sanitary. The kitchen was observed to be clean and free of hazards or chemicals. The weekly menu was posted. No bodies of water on the premises. All walkways were free from debris or hazards. LPA toured the backyard and observed it to be free from hazards. At this time, the inspection is not complete. LPA Rodriguez will be back at a later day to complete the required annual inspection. An exit interview was conducted at 1:58 p.m., and a copy of this report was given to Administrator Anjelle Skates, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 09/17/2025 at 1:00 p.m., Licensing Program Analyst (LPA) Brenda Rodriguez conducted an unannounced Annual Inspection and met with Anjelle Skates, Administrator. LPA Rodriguez disclosed the purpose of the inspection and was granted entry into the facility. The purpose of this visit was to complete the required Annual Inspection. LPA Rodriguez used the CARE Inspection Tool. The facility currently has a census of three (3) clients. LPA Rodriguez reviewed the Emergency Response Plan binder and training certificates staff has done and received. The required Annual Inspection is complete. No deficiencies were cited. An exit interview was conducted at 2:07 p.m., and a copy of this report was printed and given to Administrator Anjelle Skates, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 09/17/2025 at 1:00 p.m., Licensing Program Analyst (LPA) Brenda Rodriguez met with Anjelle Skates, Administrator, regarding an incident report that was reported to CCL on 09/09/2025. LPA Rodriguez disclosed the purpose of the inspection and was granted entry into the facility. LPA Rodriguez wanted to discuss the Incident Report that was reported on 09/09/2025. More information on Incident Report on LIC 812. LPA Rodriguez conducted one (1) confidential staff interview. An exit interview was conducted at 2:09 p.m., and a copy of this report was printed and given to Administrator Anjelle Skates, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
Control Number - 2197-FN On September 23, 2025, at 4: PM, Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced case management inspection at the above-referenced facility to follow up on a submitted Incident Report (IR). LPA met with Maria Castaneda, Youth Advocate and communicated with Administrator Anjelle Skates over the phone. At the time of the visit, two staff members and three clients were present. The IR was submitted regarding an incident that occurred on September 16, 2025. The Administrator stated that the 24-hour notification was reported to LPA Brenda Rodriguez in person during a prior visit. According to the report, Client C1 was found unresponsive, slumped over, and smelled of alcohol. Paramedics were contacted, but when C1 regained consciousness and was informed that emergency services had been called, C1 became upset and AWOLed from the facility. Paramedics and a clinician searched for C1, who was located on the same block returning to the facility. C1 was evaluated by paramedics, vitals were checked, and C1 was cleared to return to the facility. During the visit, LPA interviewed the Administrator to obtain additional information regarding the facility's plan to ensure C1 follows the safety plan discussed in the Child and Family Team (CFT) meeting and updated needs and services plan to address alcohol consumption. The Administrator stated: "We do bed checks routinely every hour. We can't control what she does off-site. She is working daily with her clinician but continues to decline all medication. We requested that she be placed in a higher level of care." Additionally, LPA discussed with the Administrator the proper procedure for documenting incidents involving law enforcement contact. LPA provided the Administrator with the LIC 624-LE form for reference, as well as PIN 23-02-CRP and PIN 17-04-CRP. No deficiencies were observed or cited during this inspection. An exit interview was conducted, and a copy of this report was provided to Maria Castaneda, Youth Advocate.

met_with: Maria Casteneda, Youth Advocate


summary: Facility Evaluation

raw_content:
Narrative:
Control Number - 2196-FN On September 23, 2025, at 4: PM, Licensing Program Analyst (LPA) Jonathan Medina conducted an unannounced case management inspection at the above-referenced facility to follow up on submitted Incident Reports (IRs). LPA met with Maria Castaneda, Youth Advocate and communicated with Administrator Anjelle Skates over the phone. At the time of the visit, two staff members and three clients were present. Several IRs were submitted between September 13 and September 17, 2025, involving law enforcement contact. Upon review, LPA observed that the reports were missing required components related to law enforcement involvement. During the visit, LPA interviewed the Administrator, Anjelle Skates over the phone to obtain additional information. LPA also discussed with the Administrator the proper procedures for documenting incidents involving law enforcement contact. LPA provided the Administrator with the LIC 624-LE form for reference, along with PIN 23-02-CRP and PIN 17-04-CRP. LPA explained that while the facility is not required to use the LIC 624-LE, any form used must include the same required information. No deficiencies were observed or cited during this inspection. However, as an area of improvement, LPA issued a technical violation under Interim Licensing Standards (ILS) Section 87061(j) - Reporting Requirements. Please refer to LIC 9102 for additional details. An exit interview was conducted, and a copy of this report was provided to Maria Castaneda, Youth Advocate.


summary: Facility Evaluation

raw_content:
Narrative:
On 11/12/2025 at 12:15 p.m., Licensing Program Analyst (LPA) Brenda Rodriguez and Licensing Program Analyst (LPA) Kaitlyn Wong met with Anjelle Skates, Administrator, regarding an incident report that was reported to CCL on 11/06/2025. LPA Rodriguez disclosed the purpose of the inspection and was granted entry into the facility. LPA Rodriguez wanted to discuss the Incident Report that was reported on 11/06/2025. More information on Incident Report on LIC 812. LPA Rodriguez conducted one (1) confidential staff interview. An exit interview was conducted at 12:40 p.m., and a copy of this report was printed and given to Administrator Anjelle Skates, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
On 02/11/2026 at 2:25 p.m., Licensing Program Analyst (LPA) Brenda Rodriguez met with Irinea Duenas, Youth Advocate, regarding an incident report that was reported to CCL on 01/27/2026. LPA Rodriguez disclosed the purpose of the inspection and was granted entry into the facility. LPA Rodriguez wanted to discuss the Incident Report that was reported on 01/27/2026. More information on Incident Report on LIC 812. LPA Rodriguez conducted one (1) confidential staff interview and two (2) confidential client interviews. An exit interview was conducted at 3:10 p.m., and a copy of this report was printed and given to Youth Advocate Irinea Duenas, whose signature on this form confirms receipt.

met_with: Irinea Duenas, Youth Advocate


summary: Facility Evaluation

raw_content:
Narrative:
On 02/11/2026 at 2:25 p.m., Licensing Program Analyst (LPA) Brenda Rodriguez met with Emma Solano-Gamboa, Youth Advocate, regarding an incident report that was reported to CCL on 02/04/2026. LPA Rodriguez disclosed the purpose of the inspection and was granted entry into the facility. LPA Rodriguez wanted to discuss the Incident Report that was reported on 02/04/2026. More information on Incident Report on LIC 812. LPA Rodriguez conducted one (1) confidential staff interview and two (2) confidential client interviews. An exit interview was conducted at 3:15 p.m., and a copy of this report was printed and given to Youth Advocate Emma Solano-Gamboa, whose signature on this form confirms receipt.

met_with: Emma Solano-Gamboa, Youth Advocate


summary: Facility Evaluation

raw_content:
Narrative:
On 02/25/2026 at 1:35 p.m., Licensing Program Analyst (LPA) Brenda Rodriguez met with Anjelle Skates, Administrator, regarding an incident report that was reported to CCL on 01/27/2026 and 02/04/2026. LPA Rodriguez disclosed the purpose of the inspection and was granted entry into the facility. LPA Rodriguez wanted to discuss the Incident Report that was reported on 01/27/2026 and 02/04/2026. LPA Rodriguez conducted one (1) confidential staff interview. LPA Rodriguez cited a Type B Citation for Personnel Duties 84065.2(b)(1), see more on LIC 9099D. An exit interview was conducted at 2:00 p.m., and a copy of this report was given to Administrator Anjelle Skates, whose signature on this form confirms receipt.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Monica Pavia scheduled a Technical Assistance (TA) meeting on above date and time. Attendees to the meeting were: Monica Pavia, Carolyn Flynn, Marjana Jackson, Levi Huser, Helen Ayala and Amanda Tucker. Items discussed: 1. Plan of Operation/Program Statement to be formatted according to STRTP Interim Licensing Standards, version 4. (Review tool received for section titles.) 2. There are no questions on the notes provided, at this time. 3. Any questions will be directed to LPA Monica Pavia. The goal is to resubmit the Plan of Operation/Program Statement by Friday, October 13, 2023.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Monica Pavia scheduled a Technical Assistance (TA) meeting, via Teams, on above date and time. Attendees to the meeting were: Monica Pavia, Carolyn Flynn, Marjana Jackson, Levi Huser, Isabella Karabed. Items discussed: 1. Plan of Operation/Program Statement to be formatted according to STRTP Interim Licensing Standards, version 4. (Review tool received for section titles.) 2. Plan of Operation: Section G - Admission Determination Procedures. Elevated review procedures were explained. 3. Plan of Operation: Section Q - Continuous Quality Improvement (CQI). Expand age appropriate feedback and include a sample of questions for clients in placement. 4. Program Statement: Core Services and Support. Additional trauma informed practices and disengagement skills to be used by staff. CPI training will be submitted as an appendix to this section. All incidents (on or off site) will be documented and reported, to Community Care Licensing (CCL), on an Unusual Incident/Injury Report (LIC624) or Law Enforcement Contract Report (LIC624-LE). 5. Any questions will be directed to LPA Monica Pavia. The estimated re-submission of the Plan of Operation/Program Statement is Friday, October 20, 2023.

met_with: Isabella Karabed, Program Director


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analysts (LPA) Monica Pavia and Jasmine Cardeno made an announced site inspection, for the purpose of preparing for a prelicensing inspection, at a later date. LPAs met with Facility Manager, Anjelle Skates, who provided a tour of all buildings on the campus. LPAs observed the following items that need to be addressed prior to a prelicensing inspection to be scheduled. 1. Capacity request for Short-Term Residential Therapeutic Program (STRTP) application must not exceed bedroom space available for children in placement. No more than 2 children shall share a bedroom. 87087(b)(1) 2. Program shall not have more beds for children's use than required for the maximum capacity approved by the licensing agency. 87088(c)(1)(A) 3. LPA will check camera policy with CCL policy department. Cameras are never allowed to be used in lieu of staff supervision. 87078(b) 4. Bunk beds are not allowed for this population. 87088(c)(1)(C) 4. Hot water temperature shall be maintained between 105 and 120 degrees Fahrenheit. 80088(e)(1) 6. All sharps and poisonous cleaning supplies must be kept locked. 80087(g)(1) 7. Dining room must provide necessary space for licensed capacity. 87087.3(a) 8. Extra linens to be made available in children's living quarters. 80088(g) 9. All food must be covered in the refrigerator/freezer. 10. Display Personal Rights, Menus and Complaint Policy/Grievance Forms in each building on campus, accessed by children in placement.


summary: Facility Evaluation

raw_content:
Narrative:
On June 3, Licensing Program Analyst (LPA) Monica Pavia met with Facility Manager/Administrator, Anjelle Skates for a prelicensing inspection. LPA discussed the following with Anjelle Skates: Forms that the facility uses and will continue to use. Corporate organization - Including chain of command and roles of staff Written plans, policies or procedures that was submitted with the application. Administrator qualifications and duties. 1. Facility grounds were inspected. There are several structures on facility grounds. Joy House will be utilized as the residential house for the Short-Term Residential Therapeutic Program (STRTP) license, capacity of 8. (Capacity on this report will be updated.) All buildings/structures on facility grounds, not in use, will be kept locked. Grounds are clean and free from observable hazard. The facility does not have a swimming pool or any bodies of water. Firearms are not allowed on facility premises. 2. Adequate indoor activity space and materials observed, and outdoor activity space was observed. 3. Chemicals were appropriately locked. 4. Procedures for Locked and centrally stored medications observed. 6. Adequate storage space observed. 7. Individual beds in good repair observed. A supply of extra linens available for bed changes. 8. Joy house has 4 client bedrooms, double occupancy and 2 client bathrooms. Bedrooms are accommodating of all required furnishings. 9. Adequate food storage space observed. Facility will add appropriate supply of foods upon placement of youth in the home. 10. Sample menu posted. 11. All appropriate forms posted within client view. 12. Dining room equipped with large table and chairs accommodating of all clients. 13. Hot water measured 109.4 degrees on this date. Applicant and staff are associated through Guardian and have been fingerprint cleared. Discussed Incident reporting. An initial report for all reportable incidents is to be made by the next working day, either verbal or written. A full report is to be remitted within 7 days via email to SBIRCR@dss.ca.gov. All applications require a secondary review from a Licensing Program Manager (LPM). Once reviewed and approved by LPM, this STRTP facility will be ready for licensure. A copy of this report was emailed to Anjelle Skates.


facility_name: JR'S NORTH STAR II

summary: Facility Evaluation

raw_content:
Narrative:
On 6/16/2021 at 9: AM, Licensing Program Analyst (LPA) Shikya Belfield initiated an annual /required inspection at the above facility. Upon entering the facility LPA Belfield was greeted by administrator Tangie Jackson and Jamie Richard who assisted with the inspection. Present during this inspection were three staff and two clients. A tour of the facility was conducted, observed during the time of the inspection were the following; posted forms: all forms required to be posted such as license, personal rights, facility sketch, meal menu, and activity calendar, were all posted. Smoke detectors were located and are in working condition. The facility was observed to be clean and in good repair. Food supply was sufficient for non-perishable food and perishable food for one week. LPA interviewed C1 and C2 ( see LIC 811 dated 6/16/2021). The water temperature was below 120 degrees which is within the requirements of the regulations. During this inspection LPA Belfield reviewed staff files and client files. During a file review it was observed in the Licensing information System that they were no active fingerprints for S2 ( see Lic 811 dated 6/16/2021) however, LPA Belfield observed paper work showing an approved exemption status from the department. At this time it is unclear what happened to cause a conflict of information in the system. LPA discussed with administrator Jackson, that S2 needed to stop working until the issue with their finger prints were resolved. LPA observed all client and staff records to be up to date and complete. LPA Belfield discussed medication logs with administrator Jackson and reminded administrator that Psychotropic medications must be documented separately. All medication logs are current and complete. LPA observed medications remaining. Also discussed were the use of medication forms. LPA informed administrator Jackson that the program could create their own forms to log medication as long as it has all of the required information according to the regulations. Advisory issued for section, 80070(a) client records. During a client file review it was observed by this LPA that C4 did not have an immunization record. This was due to the client being recently placed and files were being obtained by the county worker as stated by administrator Jackson. LPA Belfield conducted interviews with C4 and C5 who were present in the facility. Advisory issued for of California Code of Regulations, Title 22, Division Six, section 80070(a) Client Records. There were no violations of California Code of Regulations, Title 22, Division Six or Interim Licensing Standards, cited during this inspection. An exit interview was conducted with administrator Jackson and a copy of this report will be sent to Licensee Jamie Richard and administrator Jackson.

met_with: Tangie Jackson


summary: Facility Evaluation

raw_content:
Narrative:
On Friday May 13, 2022 at 11: AM Regional Manager, Nelson Martinez, Licensing Program Managers (LPM's) Carolyn Flynn, Helga Wong and Isabel Mendoza conducted an office meeting virtually via Microsoft Teams. Community Care Licensing (CCL) met JR Northstar I Administrator, Rachel McCormick and Consultant, Tricca Leverenz. Tandreya Jackson was unable to attend. The purpose of this meeting was to discuss the Mental Health Program Approval (MHPA) and the required items for permanent licensure for JR Northstar I & II. The facility's 24 month STRTP provisional expires on June 30, 2022. The facility submitted their MHPA to DHCS on April 12, 2022. DHCS cannot move forward with the application until the facility finds a qualified Head of Service and the facility is contracted by Contra Costa County Behavioral Health. At this time, the county is expected to finish their review by August of 2022. During this meeting the following options were discussed; withdrawal of STRTP application by the program, this would prevent CCL (Community Care Licensing) from taking legal action against the program. The facility was informed that if the program is not able to obtain their Mental Health approval by the date of June 30, 2022 the department will have to take legal action. The facility was also informed that they could withdraw their STRTP application and submit a plan of closure. The facility will have an internal discussion, and the Administrator, Rachel McCormick will contact LPM Mendoza on when they will submit their closure plan to CCL, or notify LPM if there are any immediate changes with DHCS or their county contract. A copy of this report was emailed to the facility for signature.

met_with: Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 08/10/22 at 9: AM Licensing Program Analysts (LPA's) Alyssa Ng and George Karkazis conducted an unannounced case management inspection. The purpose of the inspection was to confirm that the above address ( Page Court, Pinole, CA) is no longer operating as a Children's Residential Facility and has no children in placement. The house is a two story home in a residential neighborhood. Assistant Executive Director Rachael was present and had construction staff remodeling the house. During inspection, it was confirmed that the above address is no longer a residential facility. Assistant Executive Director Rachael also gave me their license. JR's North Star II is officially closed and the license forfeited.

met_with: Rachael McCormick


facility_name: JR'S NORTH STAR, INCORPORATED

summary: Facility Evaluation

raw_content:
Narrative:
At 11:10am, Licensing Program Analyst (LPA) made an announced inspection to interview a client in placement for a complaint investigation. LPA met with Jamie Richard, Staff, who helped facilitate the inspection. At 11:15am, LPA interviewed Client 1 (C1) on the outside porch of the facility. An exit interview was conducted and a copy of this report was emailed to staff. .

met_with: Jamie Richard


summary: Facility Evaluation

raw_content:
Narrative:
On 6/16/2021 at 9: AM, Licensing Program Analyst (LPA) Shikya Belfield initiated an annual /required inspection at the above facility. Upon entering the facility LPA Belfield was greeted by Licensee Jamie Richard who assisted with the inspection. Present during this inspection were one staff and three clients. A tour of the facility was conducted, observed during the time of the inspection were the following; posted forms: all forms required to be posted such as license, personal rights, facility emergency evacuation plan, and meal menu, were all posted. Also posted were most recent fire clearances and recently purchased fire extinguishers. Smoke detectors were located in each client bedroom as well as the main area of the facility and are in working condition. The facility was observed to be clean and in good repair. Food supply was sufficient for non-perishable food and perishable food for one week. Due to the facility being affected by the pandemic, Licensee states they grocery shopping is completed twice a week and that the program now utilizes a grocery delivery service to assist. Due to the recent accreditation process that the program had completed, the facility's client and staff files were temporary relocated at the second location. LPA Belfield will review the files at that location. Medication logs and location were in a locked file cabinet. Client's rooms were clean and all bedding had proper linen. One client's bed was observed to have the box spring off the rails, however this was adjusted during the inspection. LPA observed client files for the three clients that are currently placed in the facility, C1, C2, and, C3 ( see LIC 811 dated 6/16/21). C1 and C2 allowed this LPA to look in their room briefly and did not want this LPA to see their closet. C3 did not want this LPA to look in their room at all, however they changed their minds and asked this LPA to observe. All client's rooms were clean and in good repair. No violations of California Code of Regulations, Title 22, Division Six, or Interim Licensing Standards were cited during this inspection. An exit interview was conducted with Licensee and a copy of this report will be sent to Licensee Jamie Richard.


summary: Facility Evaluation

raw_content:
Narrative:
On Friday May 13, 2022 at 11: AM Regional Manager, Nelson Martinez, Licensing Program Managers (LPM's) Carolyn Flynn, Helga Wong and Isabel Mendoza conducted an office meeting virtually via Microsoft Teams. Community Care Licensing (CCL) met with Administrator, Rachel McCormick and Consultant, Tricca Leverenz. The purpose of this meeting was to discuss the Mental Health Program Approval (MHPA) and the required items for permanent licensure for JR Northstar I & II. The facility's 24 month STRTP provisional expires on June 30, 2022. The facility submitted their MHPA to DHCS on April 12, 2022. DHCS cannot move forward with the application until the facility finds a qualified Head of Service and the facility is contracted by Contra Costa County Behavioral Health. At this time, the county is expected to finish their review by August of 2022. During this meeting the following options were discussed; withdrawal of STRTP application by the program, this would prevent CCL (Community Care Licensing) from taking legal action against the program. The facility was informed that if the program is not able to obtain their Mental Health approval by the date of June 30, 2022 the department will have to take legal action. The facility was also informed that they could withdraw their STRTP application and submit a plan of closure. The facility will have an internal discussion, and the Administrator, Rachel McCormick will contact LPM Mendoza on when they will submit their closure plan to CCL, or notify LPM if there are any immediate changes with DHCS or their county contract. A copy of this report was emailed to the facility for signature.

met_with: Rachel McCormick


summary: Facility Evaluation

raw_content:
Narrative:
On 8/22/22 at 10: AM, Licensing Program Analysts George Karkazis and Alyssa Ng conducted an unannounced Annual/Random at listed facility. LPA's met with Jamie Richard, Executive Director(ED) and toured the facility inside and out. The group home is currently licensed to serve 6 clients, currently there are four clients. Present during the inspection were three staff and three clients. At 10:50am, LPA's toured the facility. LPA saw three bedrooms and three bathrooms. Two bathrooms were for clients and one was for staff. LPA's observed the facility license, personal rights, facility sketch, facility rules, and other forms posted[ on the walls throughout the facility. LPA Karkazis interviewed one client and two staff. LPA Karkazis and Ng reviewed staff and client files. The needs and services plans were not up to date. The facility menu was not posted in the kitchen. LPA's advised ED to have the facility menu posted. All staff were fingerprinted and had child abuse index check clearances. LPA Karkazis tested the water temperature and found it to be 114 degrees, which is in within range. Thermostat read 68 degrees, within range. At 11:00am LPA's walked through the backyard. There were no open bodies of water. LPA's observed a pile of miscellaneous tools, cardboard, lawn furniture, and debris. ED explained that the house was under construction and that some of the debris was from the closure of their other facility. LPA's advised ED to have the pile removed and cleaned. There were 2 days of perishable foods and 7 days of non-perishable foods present. Sharps and chemicals were located in a locked staff closet. The medication was also stored away in a locked staff closet. Facility cited for Interim Licensing Standards, Title 22, Division 6, regulation 87070(b)(18). See attached 809-D. At this time, there were one deficiency, one technical violation, and one technical advisory during this inspection. An exit interview was conducted, appeal rights discussed, and a copy of this report was left at this facility, with Rachael McCormick, director.

met_with: Jammie Richard


summary: Facility Evaluation

raw_content:
Narrative:
On 2/2/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a case management visit at the facility to confirm closure. LPA called and spoke to Assistant Executive Director Rachael McCormick during visit. There was no one present and no response to the doorbell. Asst. Executive Director confirmed that the facility was closed and the house was empty and that the paper license will be sent to LPA. An exit interview was conducted, and a copy of this report provided to Asst. Executive Director, who agreed to receive a copy and return to LPA signed.

met_with: Asst. Executive Director Rachael McCormick


facility_name: KIDS TO KIDS- FAITH HOUSE

raw_content:
Narrative:
Although there is evidence indicating implementation of established AWOL policy and staff intervention, neglectful behavior and/or lack of resident oversight cannot be confirmed with C1 due to unknown whereabouts and lack of impartial witnesses. Therefore, it must be concluded that an allegation of neglect/lack of supervision cannot be substantiated at this time. There are no deficiencies to be cited at this time. Exit Interview conducted, and a copy of this report was left at the facility.

Investigation Findings:
13On June 30 2022 at , Licensing Program Analyst (LPA) Kuliema Calloway and Licensing Program Manager (LPM), Kevin Sauk made an unannounced inspection to the above facility for the purpose of concluding the investigation on the above allegation and to deliver the findings. LPA spoke with Facllity Administrator (FA) and together, discussed the investigative findings. [See confidential names form LIC 811 dated 6/30/2022). During the investigative process by Licensing program Analyst (LPA), Nancy O'Connell, all relevant parties have been accounted for. Based on the interviews conducted and documents obtained, the above allegation is found to be Unsubstantiated, meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Supporting evidence includes: unsuccessful attempts to locate and interview victim due to multiple changes in placements, review of facility AWOL policy, consistent staff reports demonstrating understanding of AWOL policy, and review of fifteen SIRs reporting C1s AWOLs along with staff attempts to intervene. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Kuliema Calloway 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: KIDS TO KIDS- FAITH HOUSEFACILITY NUMBER: VISIT DATE: 06/30/2022

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

met_with: David Yasutake, Administrator


raw_content:
Narrative:
On 03/08/2021 at approximately 6:00, Client#1 (C1) runway way (AWOL) from the facility. Facility staff attempted to redirect C1 and was offered to go on a walk, do activities, and have a one-on-one with staff. Facility had the Crisis Team on call with C1. C1 hang up on the Crisis Team but at approximately at 7:30pm, C AWOL from the facility. Facility contacted Ventura County Police Department to report missing person report. C1 was gone for approximately two hours. At around 9:45pm, C1 reached out to Facility Staff to report that she left to the Vons shopping center near the facility and that she was in a car on unknown man. Facility staff and Law Enforcement arrived the Vons shopping center to pick up C1. Facility reported that C1 was outside of the man's car and was trying to get back in. C1 and unknown man reported a different description of the incident. C1 was offer medical assistance and was given counsel that was not able to determine if the incident did happen. Results from the Department's investigation, consisting of interviews with related parties, inspections, and review of records. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. The Department has decided that the allegations of Neglect and Lack of Supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There were no deficiencies observed or cited at this time. Exit interview was conducted with S1 and a copy of this report was left at the facility.

Investigation Findings:
13On July 28, 2022, at 09:30am, Licensing Program Analyst (LPA) Olivia Rosas conducted an unannounced inspection to Kids to Kids- Faith House Short Term Residential Therapeutic Program (STRTP) for the purpose of concluding the investigation on the above allegation and to deliver the findings. LPA Rosas, met with Staff#1 (S1) and together discussed the investigation details. During the investigation process, LPA Rosas interviewed witnesses and pertinent parties related to the investigation. Individuals mention in this complaint are identify on the Confidential Names List (LIC811) dated June 28, 2022. Based on the confidential interviews conducted during the investigation process, record review, statements obtained, LPA Rosas determined that Neglect/Lack of Supervision allegation that facility staff did not prevent a minor from running away (AWOL), may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the findings are unsubstantiated. Report continues on LIC-9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Olivia Rosas 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: KIDS TO KIDS- FAITH HOUSEFACILITY NUMBER: VISIT DATE: 07/28/2022

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

met_with: Facility Manager


raw_content:
Narrative:
On 03/12/2021 at approximately 4:20pm, Client#1 (C1) runaway (AWOL) from the facility. Staff#2 (S2) offer a one-on-one walk around the neighborhood. During the walk C1 separated herself from S2. S2 followed until C2 was able to get out of eyesight. Facility contacted Ventura County Police Department to report missing person report. Facility staff reported, that C1 was habitual AWOLer. Facility staff described how they try to redirect clients from running away by offering to go on a walk, do activities, and adding extra supervision. Results from the Department's investigation, consisting of interviews with related parties, inspections, and review of records. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. The Department has decided that the allegations of Neglect and Lack of Supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There were no deficiencies observed or cited at this time. Exit interview was conducted with S1 and a copy of this report was left at the facility.

Investigation Findings:
13On July 28, 2022, at 09:30am, Licensing Program Analyst (LPA) Olivia Rosas conducted an unannounced inspection to Kids to Kids- Faith House Short Term Residential Therapeutic Program (STRTP) for the purpose of concluding the investigation on the above allegation and to deliver the findings. LPA Rosas, met with Staff#1 (S1) and together discussed the investigation details. During the investigation process, LPA Rosas interviewed witnesses and pertinent parties related to the investigation. Individuals mention in this complaint are identify on the Confidential Names List (LIC811) dated June 28, 2022. Based on the confidential interviews conducted during the investigation process, record review, statements obtained, LPA Rosas determined that Neglect/Lack of Supervision allegation that facility did not adequately supervise group home child, may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred, therefore the findings are unsubstantiated. Report continues LIC-9099C UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Olivia Rosas 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: KIDS TO KIDS- FAITH HOUSEFACILITY NUMBER: VISIT DATE: 07/28/2022

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

met_with: Staff#1 (S1)


raw_content:
Investigation Findings:
13On September 20, 2022, at 10:30 a.m., Licensing Program Analyst (LPA), Kuliema Calloway, made an unannounced visit to the above facility for the purpose of concluding complaint findings. LPA met with Daniel Bakst, Head of Service at Kids to Kids Faith House who granted access. Based on the interviews with three out of six clients and three staff, the investigation revealed conflicting states, where it is unclear whether staff (S1) handled the client (C2) in a rough matter. [See LIC 811, dated 9/20/2022]. Based on review and analyzing all evidence, the LPA has found this complaint to be Unsubstantiated, meaning the allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. There are no deficiencies to be cited for this allegation. A copy of this report and appeal rights were provided to Daniel Bakst at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Kuliema Calloway 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: Daniel Bakst, Head of Service


raw_content:
Narrative:
continued from page 1 (LIC 9099) On November 11th, AGPA Woodard conducted a subsequent inspection to the facility for the purpose of gathering additional supporting documentation. Confidential interviews and a review of supportive documentation revealed that Law Enforcement responded to calls at the above facility 22 times for assaults, missing persons, suspicious circumstances, and follow-up investigations. Staff did follow the runaway procedures by contacting the non-emergency number to place a missing person report, provided important information regarding the minor and photo identification, and when the client returned the facility staff contacted the police department to close the missing persons' report. The habitual runaways did receive citations from law enforcement, and when a client was gone longer than 24 hours, a child and family team meeting was held to implement prevention interventions. Based on confidential interviews and review of supportive documentation, AGPA Woodard determined the lack of supervision allegation that staff do not provide adequate supervision to minors, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the findings are unsubstantiated. A copy of this report was left at the facility.

Investigation Findings:
13On November 22, 2022 at 1:10PM, Associate Governmental Program Analyst (AGPA) Tonya L. Barnes-Woodard conducted an unannounced complaint inspection at Kids to Kids - Faith House for the purpose of concluding the investigation and to deliver the findings. Upon arrival, AGPA Woodard was greeted by Lina Severino, Facility Manager. On November 3, 2022 the Department received a complaint regarding the above allegation. AGPA Woodard conducted the initial 10-day inspection on November 6th, 2022 and confidential interviews were conducted with two staff and two clients. On November 10th, AGPA Woodard conducted confidential interviews with the Reporting Party and HOS. continue on page 2 (LIC 9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Tonya Barnes-Woodard 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: KIDS TO KIDS- FAITH HOUSEFACILITY NUMBER: VISIT DATE: 11/22/2022

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

met_with: Lina Severino


raw_content:
Investigation Findings:
13On March 7, 2023 at 9:15am, Licensing Program Analyst (LPA) Nancy O'Connell made an unannounced inspection to the above facility for the purpose of concluding the investigation on the above allegations and deliver the findings. LPA spoke with FM and together, discussed the investigative findings. During the investigative process by Licensing program Analyst (LPA), Nancy O'Connell, all relevant parties have been accounted for. Supporting evidence includes: conflicting interview statements with house residents and staff members that reflected minimal evidence as to whether allegations occurred. Further, record reviews indicate evidence of provision of therapeutic services, administration of medication, and attempts to coordinate a 14-day notice for C1 with the placing county. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. No deficiencies are being cited at this time. Exit Interview conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Kevin C Sauk LICENSING EVALUATOR NAME: Nancy O'Connell 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: Madison Pennington, Facility Manager (FM)


raw_content:
Narrative:
--(Continued from page LIC9099)-- Based on confidential statements and record review, the allegation concerning staff selling and distributing illegal drugs at the facility cannot be substantiated due to a lack of evidence. The findings are 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 were no deficiencies cited per Short-Term Residential Therapeutic Program Interim Licensing Standards or California Code of Regulations, Title 22, at this time. Exit interview completed. A copy of this report and LIC811 was provided to the Facility Representative Exit interview conducted with Facility Representative. A copy of this report and appeal rights are left with Representative.

Investigation Findings:
13On June 9, 2023, at 2: PM, Licensing Program Analyst (LPA) Regina Martin conducted a follow-up complaint inspection to deliver findings from the Department's investigation. LPA met with Facility Representative, Madison Pennnington Facility Manager to discuss the outcome. On July 19, 2022, Community Care Licensing Division (CCLD) received an allegation that staff (unidentified) are selling and distributing illegal drugs at the facility. The allegation was referred to CCLD Investigations Bureau, Investigator Douglas Real. On July 21, 2022, LPA Regina Martin conducted the initial complaint inspection, met with the facility Manager and reviewed records. The investigation further consists of confidential interviews of youth and related parties, as well as review of facility file history. Confidential statements and record review revealed a lack of evidence to prove the alleged as information obtained determined no witnesses or corroborating evidence to substantiate reported claim. (Continued on page LIC9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Regina Martin 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: KIDS TO KIDS- FAITH HOUSEFACILITY NUMBER: VISIT DATE: 06/09/2023

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


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Sethany Yem conducted a case management inspection on October 27th, 2021 at 11:00am, based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. 4 of Staff and 4 of 6 youth files as identified on the LIC 811 confidential names dated October 27th, 2021, were reviewed. 3 of Staff and 2 of 6 youth were also interviewed. The Plan of Operation including policies and procedure were reviewed. A copy of this report was discussed and provided to CEO/ Administrator David Yasutake.

met_with: CEO/ Administrator David Yasutake


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Nancy O'Connell made an unannounced inspection to the Kids to Kids- Faith House on 04/29/2022 at 10:50am for the purpose of conducting an Annual/Required Inspection. LPA O'Connell met with the Facility Manager (FM), Lina Severino, who granted access to the facility. The entire physical plant was inspected, inside and out. The facility is licensed to care for six (6) female clients, ages 13-17 years, ambulatory only (See confidential name list LIC811 dated 04/29/2022). This is a three-bedroom, two-bathroom, single story family residence that includes a living room, dining area, kitchen, laundry area and a carport. Annual fee is current. LPA inspected the facility with the the FM and observed the following: Bedroom #1: Is occupied by Client#1 (C1) and it has two full size beds, adequate closet and drawer space. Bedroom #2: Is occupied by Client#2 (C2) and it has two twin size beds, adequate closet and drawer space. Bedroom #3: Is occupied by Client#3 and Client #4 (C3 and C4) and it has two twin size beds, adequate closet and drawer space. There is no bodies of water on the premises. The smoke detector was tested and is functional. The passageways, stairways, and open porches are unobstructed. The menu with date is posted in the kitchen. Documents posted in the main hallway: client's personal rights, grievance procedure, emergency exit plan, referral number for licensing agency, and facility license. The outdoor space is clean, clear and free of debris. Knives are locked in the staff office, and clients do not have access to them. Chemicals are kept in a locked closet where clients do not have access. Continued on LIC809C Medication is locked and accessible only to the facility manager and staff that are on shift. LPA observed a fully charged fire extinguisher in the staff main office. Refrigerator was inspected and perishable food was available for at least 2 days, and non-perishable food items were stocked in pantry. Fruit was available on kitchen counter. Facility truck was inspected and in good working condition with current registration and insurance. At the time of inspection, LPA O'Connell reviewed the LIC 500 and obtained information that a staff SI, S2 and S3 has been scheduled for work and does not have clearance in Guardian to provide services. LPA discussed matter with the Facility Manager and Facility Administrator, and all agreed that an immediate civil penalty would be assessed, and staff would not be allowed to return to the facility until clearance can be obtained. LPA discussed outcome of visit with the facility administrator and left a copy of this report on site.


summary: Facility Evaluation

raw_content:
Narrative:
On September 20, 2022, at 11: AM., Licensing Program Analyst (LPA) Kuliema Calloway conducted a Case Management - Incident inspection at the above said facility, and met with the Daniel Bakst, Head of Service in response to a Special Incident Report, submitted to Community Care Licensing (CCL), in order to investigate a possible violation. The incident, which occurred on September 9, 2022, involved client (C1), who reported they drank Lysol with water [See LIC Confidential Names List form (LIC 811), dated September 20, 2022, for names]. C1 was transported to Community Memorial Hospital Emergency room, where C1 was later placed on a 5585 hold. Because Clients (C1, C3, and C4) were not at the facility at the time of this inspection, LPA conducted interviews with staff (S1 and HS). Further investigation is needed for a final resolution. Per California Code Regulation, there are no deficiencies to be cited at this time. Exit Interview conducted, and a copy of this report was left with Daniel Bakst at the facility.


facility_name: KIDS TO KIDS- RESTORATION

summary: Facility Evaluation

raw_content:
Narrative:
On May 6, 2021, Licensing Program Analyst (LPA) Regina Martin conducted a Case - Management Incident inspection to deliver and discuss findings from the Department's Investigation on self- reported incident received July 21, 2020. LPA met with Facility Representatives, Shannon Walling, Facility Manager and Andrea Espinosa Senior Facility Manager and together discussed investigation details. On July 21, 2020, Community Care Licensing received an incident report from facility representatives reporting that Staff member #1 (S1) contributed marijuana to minors. The incident was referred and assigned to Investigations Bureau, Investigator, Dennis Douglas. The investigation revealed, according to gathered information from independent interviews and review of corresponding records including incident reports and reports from the Ventura County Police Department, S1 provided and smoked marijuana with several of the clients at the facility. The marijuana was provided by S1 to the clients in the form of a "wax pen" and a "pipe". Sources revealed the encounters would occur outside of the facility during "walks" or while S1 was in the facility vehicle with the clients. S1 admitted to Investigator Douglas that she provided and smoked marijuana with the minor clients. Confidential independent interviews with clients residing in the facility at the time, further corroborate claims as some residents admitted to smoking marijuana out of S1's "wax pen" with S1 on several occasions and S1's "pipe" on at least one occasion. Upon discovery of said incident, S1 was terminated from her position at the facility. Facility representatives notified all required parties and conducted an internal investigation pertaining to the incident. (Continued on pg. Lic809d) Corrections concerning facility policy and procedures pertaining to this incident were reviewed and updated as necessary. Based on gathered information there is corroborating evidence to support reports of S1 contributing marijuana to minors. S1's actions towards clients poses an immediate health, safety and personal rights risk to children placed in care. The facility is issued a citation in accordance with Health and Safety code HSC 1558 (a)(2) Conduct inimical. See page 809D for deficiency. Exit interview conducted; Appeal Rights issued. A copy of this report was emailed to Facility Representatives.

met_with: Shannon Walling, Facility Manager; Andrea Espinosa,Senior Manager


facility_name: KIDS TO KIDS - SERENITY HOUSE

raw_content:
Narrative:
C1 was not interviewed during the investigation process due to AWOL status (absent without permission). C1's bed was officially closed on 10/23/2020. LPA Martin further interviewed two youth residents who deny observing, being a victim or having knowledge of alleged sexual abuse in the facility and further report being happy and satisfied with their living experience in the facility. The results from the investigation determined unsubstantiated finding at this time meaning, Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove sexual abuse on C1 or that a violation occurred; therefore, the above allegation is unsubstantiated. There were no deficiencies cited during the investigation process. Exit interview conducted; a copy of this report was emailed to Facility Representatives.

Investigation Findings:
13On May 6, 2021, Licensing Program Analyst (LPA) Regina Martin conducted a follow-up complaint inspection to deliver and discuss findings from investigation by the California Department of Social Services, regarding violation of Personal Rights. LPA met with Facility Representatives, Shannon Walling, Facility Manager and Andrea Espinosa, Senior Manager and discussed investigation details. On November 4, 2020, the Department received claims alleging sexual abuse on Client #1 (C1) while in care [see Confidential Names form, dated 5/6/21]. The allegation was referred to Investigation Bureau consisting of interviews with relevant related parties including, but not limited to, C1's assigned social worker, staff and family members. Records reviewed revealed C1 resided at the facility from 10/08/2020 through 10/16/2020, at which time C1 left the facility without permission and did not return. (Continued on pg. LIC9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Alan Henry LICENSING EVALUATOR NAME: Regina Martin 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: KIDS TO KIDS - SERENITY HOUSEFACILITY NUMBER: VISIT DATE: 05/06/2021


raw_content:
Investigation Findings:
13On June 25, 2021 at 1:20pm Out of State Group Home Analyst Sarah Waklee called Kids to Kids Serenity House, Senior Manager to discuss the above allegation. Analyst Waklee made multiple attempts to contact the named youths Social Worker, all of which were unanswered and voicemails unreturned. The named youth is no longer at the facility, therefore Analyst Waklee was unable to interview the youth. Based on confidential interviews with staff, Analys Waklee determined that the allegation is unsubstantiated. An unsubstantiated finding means, although the allegation may have happened, the preponderance of evidence does not prove it. A copy of this report was provided to Kids to Kids Serenity House. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Sarah Waklee 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 2

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

met_with: Andrea Espinosa, Senior Manager


raw_content:
Investigation Findings:
13On July 2, 2021 at 3:45 pm Out of State Group Home Analyst Sarah Waklee called Kids to Kids Serenity House, Senior Manager to discuss the above allegation. Analyst Waklee made multiple attempts to contact the named youths Social Worker, all of which were unanswered and voicemails unreturned. The named youth is no longer at the facility, therefore Analyst Waklee was unable to interview the youth. Based on confidential interviews with staff, Analys Waklee determined that the allegation is unsubstantiated. An unsubstantiated finding means, although the allegation may have happened, the preponderance of evidence does not prove it. A copy of this report was provided to Kids to Kids Serenity House. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Sarah Waklee 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 2

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


raw_content:
Narrative:
per California Code Regulations, Title 22, Division 6, Chapter 1, 80074(c) Transportation / Interim Licensing Standards 87074 (d)(e) Transportation on the attached LIC 9099D. A Type "A" citation for Immediate Health & Safety Hazard has been issued. Exit interview conducted. Copy of this Report and Appeal Rights emailed to Facility Representative. Exit interview conducted. Copy of Report and Appeal Rights also given to Facility Representative.

Investigation Findings:
SubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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

met_with: Manager Lina Severino


raw_content:
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: Dan Bakst, Head of Service