raw_content:
Investigation Findings:
13Licensing Program Analyst (LPA) Jessica Rodriguez conducted a complaint inspection and met with Program Manager, Fatima Gamez. The purpose of the inspection was to deliver the findings for the above complaint allegations. LPA conducted investigation that included interviews of staff and clients and review of documentation. Although the allegations may have happened or are valid, per information obtained during interviews there was not a preponderance of evidence to prove allegations occurred. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the Program Manager. There are no deficiencies to be cited on this date. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Jessica Rodriguez 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: 2 of 2

met_with: Fatima Gamez


state: CA

facility_name: CELESTE HOUSE

summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual inspection was conducted by Licensing Program Analyst (LPA) Jessica Rodriguez at Celeste House in Fresno, CA. LPA met with Program Manager, Fatima Gamez. A physical plant inspection was completed and included the following checks: Outdoor facility grounds are clean and free of debris. Adequate indoor and outdoor activity space and materials observed. All facility smoke detectors and carbon monoxide detectors are in appropriate working order, fire extinguisher is properly charged and serviced. Facility maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted. Medications are locked and centrally stored. Individual beds were observed with appropriate clean linens and are in good repair. No firearms or weapons are allowed in the facility. Facility utilizes cameras without audio in common areas of the facility. There are no bodies of water. Facility appears to be meeting the terms and conditions of their license. LPA reviewed six client files. LPA conducted three staff interviews and two client interviews. An annual continuation will be completed at the facility main office to review staff files. It is requested that the licensee submit the following updated forms to CCL: LIC 308, 309, 500 and emergency disaster plan. In addition, the most recent minutes for the Board of Directors meeting. There are no deficiencies to be cited on this date.

report_type: Facility Evaluation

visit_type: Annual


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Jessica Rodriguez conducted an unannounced annual inspection of staff records and training for the above facility. The inspection was conducted at the corporate offices of KYJO. LPA was met by Human Resource Assistant, Cameron Feraro. A review of staff records on 12/01/2021 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. LPA was unable to complete review of staff files due to technical issues. LPA was unable to leave a report with the agency as a result. The annual inspection will be completed at a later date.

visit_type: Case Management

met_with: Cameron Feraro.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Jessica Rodriguez conducted an unannounced annual inspection of staff records and training for the above facility. The inspection was conducted at the corporate offices of KYJO. LPA was met by Human Resource Assistant, Cameron Ferraro. A review of staff records on 12/01/2021 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Facility has a valid waiver on file dated November 7, 2016, to alternatively associate all staff to the central "Administrative File" which is the Barstow facility. LPA continued inspection of staff records and training. LPA observed a deficiency in regard to staff qualifications for two staff and discussed this with Human Resource Assistant, Cameron Ferarro. Interim Licensing Standards are being cited on the attached LIC 9099D. Additionally, it is requested licensee submit a closure plan to the Department, due to pending STRTP Mental Health Program Approval. Facility Provisional License Extension is due to expire December 13, 2021. An exit interview was conducted, and a copy of this report given to the agency.


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian on 03/04/2022 at 9:00AM. During the inspection, LPA Melikian met with Virginia Hernandez and Dekeydra Mothershed, Administrators, and inspected the facility inside and out. LPA reviewed three children's records on site at the facility at 9:30AM. LPA reviewed two staff personnel records on site at the facility at 10:15AM. LPA reviewed three children's psychotropic medications and medication records at 10:35AM. LPA interviewed two staff at 10:50AM. LPA interviewed one child at 11:00AM. The other two children were in school and will be interviewed at a later time. LPA conducted exit interview with Dekeydra Mothershed, Administrator at 11:15AM. LPA provided the summary report to Dekeydra Mothershed, Administrator upon completion. There were no deficiencies to be cited on this date.

met_with: Dekeydra Mothershed, Virginia Hernandez


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB484 follow up Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian on 03/04/2022 at 2:45PM. Met at the facility by Residential Youth Counselor Irene Carrillo. Clients interviewed at 3:15PM. There are no deficiencies to be cited on this date.

met_with: Irene Carrillo


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Corina Carrillo conducted a case management inspection May 4, 2022 at 10:15AM, based on the number of relevant law enforcement contacts reported by the facility, pursuant to Health and Safety Code section 1538.7. During this inspection, 5 out of Direct Care Staff and 3 out of 3 youth files were reviewed. 2 out of Direct Care Staff and 2 out of 3 youth were interviewed. (See the Confidential Names List, LIC 811, dated May 4, 2022. The Plan of Operation including policies and procedures were reviewed. Minutes from the board of directors' meetings related to the facility's incidents involving contact with law enforcement were reviewed. Based on the analysis of the confidential interviews and youth file review including the needs and service assessments, youth case plans, quarterly assessments, and crisis intervention plans, the licensee uses trauma-informed and evidence-based de-escalation and intervention techniques when staff is responding to the behavior of a youth residing in the facility. Interviews with youth and staff indicate the licensee prohibits calls or threats to call law enforcement as a form of discipline. LPA Carrillo observed documentation of completed training on policies and procedures on when and how to involve law enforcement in response to an incident. Training records show staff have been trained on Emergency Intervention as required. The licensee is contacting law enforcement in accordance to their Emergency Intervention Plan when there is an immediate risk of serious harm to a child or others. There are no deficiencies cited at this time. A copy of this report was discussed and provided to Shayla Taylor.

met_with: Shayla Taylor


facility_name: CENTER FOR POSITIVE CHANGES

summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
...CONTINUED Confidential interviews indicate that although C2 did chase and strike C1 with a rock while staff were present, one staff member (S2) was attempting to de-escalate C2 and keep the clients separate by having each client go in a different room just before the assault occurred. A record review of the program statement reveals that staff at the facility are unable to use physical restraint as a means of intervention. Therefore, the staff did not use any restraint but attempted to de-escalate the altercation between C1 and C2 by separating them and having them in two rooms supervised by S2; at the same time, the S1 went downstairs to call law enforcement. Based on confidential interviews and record review, the allegation that Staff (S1-S2) did not prevent a minor (C2) from causing injury to another minor (C1) in care is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of the report was provided along with appeal rights to D'Andre James, Facility Manager.

Investigation Findings:
13On February 23, 2024, at 3: PM, Licensing Program Analyst (LPA) Jacob Salem met with D'Andre James, Facility Manager of the Center for Positive Changes to deliver the findings for the above-stated allegation. LPA Salem interviewed Staff (S1-4) and Clients (C1 & C3). C2 was not interviewed due to declining to speak with LPA Salem. In addition, LPA Salem reviewed C1-C2's Needs and Services Plans and Statement of Dangerous Propensities, the facility's Program Statement, and Special Incident Reports. On November 1, 2023, Community Care Licensing (CCL) received an allegation that Staff (S1-S2) did not prevent a minor (C2) from causing injury to another minor (C1) in care. Specifically, it was reported that a C2 chased and hit C1 in the head with a rock while under staff supervision. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Center for Positive Changesfacility Number: Visit Date: 02/23/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...CONTINUED Confidential interviews indicate that although C2 did chase and strike C1 with a rock while staff were present, one staff member (S2) was attempting to de-escalate C2 and keep the clients separate by having each client go in a different room just before the assault occurred. A record review of the program statement reveals that staff at the facility are unable to use physical restraint as a means of intervention. Therefore, the staff did not use any restraint but attempted to de-escalate the altercation between C1 and C2 by separating them and having them in two rooms supervised by S2; at the same time, the S1 went downstairs to call law enforcement. Based on confidential interviews and record review, the allegation that Staff (S1-S2) did not prevent a minor (C2) from causing injury to another minor (C1) in care is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of the report was provided along with appeal rights to D'Andre James, Facility Manager. SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of 2

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

report_type: Complaint Investigation

met_with: D'Andre James, Facility Manager

complaint_status: unsubstantiated


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
According to confidential interviews, staff also offered incentives and options to prevent C1 from absconding from the facility. Regarding C1's substance abuse, confidential interviews stated that facility staff would conduct checks in client's pockets, clothing and bags whenever client would return from AWOL (absence without official leave) or home passes, as well as conduct perimeter checks on the property and confiscate any contraband found. While other confidential Information received by Licensing Office stated that these allegations had occurred. Based on interviews and confidential information obtained during the course of this investigation, the allegations that Facility Staff did not follow Child # 1's (C1) intervention plans to ensure that minor attended school, did not abscond from facility, as well as address C1's substance abuse while in care, may have occurred, however is not supported or proven by evidence. Therefore, the above allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided.

Investigation Findings:
13Licensing Program Analyst (LPA), Daniel Mena met with Facility Manager, D'andre James to discuss the investigative findings for the above stated allegations. Licensing Program Analysts (LPAs), Lucero Jauregui and Daniel Mena conducted inspections to the Short Term Residential Therapeutic Program (STRTP). No immediate hazards observed. The investigation was jointly conducted by LPAs Jauregui and Mena. LPAs Jauregui and Mena interviewed Facility Director (FD), four staff (Staff #1 (S1), Staff #2 (S2), Staff #3 (S3) & Staff # 4 (S4), two clients (Child # 1 (C1) & Child # 2 (C2), as well as reviewed client and facility records. Community Care Licensing received information on May 30, 2023, alleging that Facility Staff did not follow Child # 1's (C1) intervention plans to ensure that minor attended school, did not abscond from facility, as well as address C1's substance abuse while in care. Information obtained in confidential interviews did not corroborate the allegations with a preponderance of evidence. LPAs Jauregui and Mena obtained conflicting information during interviews. Confidential interviews denied allegations that staff failed to address C1's school attendance, absconding and substance abuse. According to confidential interviews, facility staff would encourage C1 to attend school every day by trying to prepare C1 for school with enough time, by counseling C1 on the importance of education, as well as by offering C1 incentives. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jennifer Smith LICENSING EVALUATOR NAME: Daniel Mena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: CENTER FOR POSITIVE CHANGESFACILITY NUMBER: VISIT DATE: 05/10/2024

met_with: D'andre James


raw_content:
Narrative:
...CONTINUED Confidential interviews indicated that S1 does not handle other clients in care in a rough manner. CCL also received the allegation that Staff (unnamed) are not addressing pests at the facility. It was reported there were cockroaches in the kitchen and staff were not addressing it. Confidential interviews indicated that cockroaches and other bugs were frequently seen in the facility kitchen, as well as in client bedrooms. Conflicting confidential interviews indicated that cockroaches were rarely seen at the facility, and the client who had cockroaches in their rooms required redirection with throwing away food. Confidential interviews indicated that staff have the kitchen treated for pests when cockroaches are seen. Confidential interviews and observations indicated that staff maintain the home to be clean and sanitary. CCL also received the allegation that Staff (S1) did not safeguard a resident's (C1) personal belonging. It was reported that S1 threw C1's phone after C1 placed their phone on S1's car. Confidential interviews indicated that S1 threw C1's phone on the pavement because of C1 tossing their phone on the hood of S1's car, and as a result C1's phone was damaged. A conflicting confidential interview indicated that S1 picked up and placed the phone on the front porch stairs leading to C1 becoming agitated. Confidential interviews indicated that C1 was later seen using their phone despite complaining about the phone being broken. CCL also received the allegation that Staff (S1) spoke inappropriately to a resident (C1). It was reported that S1 accused C1 of taking a knife out of the kitchen but then later found the missing knife in the kitchen. Confidential interviews indicated that S5, not S1, was the staff searching for the knife. Confidential interviews indicated that S5 told C1 they "know [C1] took the knife" and did not ask any other clients, despite C1 not taking things like that previously. Conflicting confidential interviews indicated that S5 brought all the clients into the game room to question them about the missing knife, as well as conduct a search of multiple clients' rooms. A confidential interview indicated that C1 was asked about the knife first due to C1 suspiciously teasing the staff while they were searching in the kitchen; however, other clients were asked as well. Confidential interviews indicated that the knife was eventually found in a location the staff previously searched. Continued... ...CONTINUED Based on conflicting confidential interviews and observations, the allegations that staff handled a resident in a rough manner, staff are not addressing pests at the facility, staff did not safeguard a resident's personal belonging, and staff spoke inappropriately to a resident are unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted, and a signed copy of this report and appeal rights were provided to Amber Carter, Facility Manager.

Investigation Findings:
13On January 10, 2025, at 10: AM, Licensing Program Analyst (LPA) Jacob Salem met with Amber Carter, Facility Manager of Center for Positive Changes to deliver the finding for the above-stated allegations. LPA Salem initiated a complaint inspection at the facility on 7/05/24 at 1: PM and no immediate deficiencies were observed. During the investigation, LPA Salem interviewed Clients (C1-C6) and Staff (S1-S5). LPA Salem obtained and reviewed pertinent records. On June 28, 2024, Community Care Licensing (CCL) received an allegation that Staff (S1) handled a resident (C1) in a rough manner. It was reported that C1 entered the office to obtain a snack and S1 grabbed and pushed C1. A confidential interview indicated that S1 pushed C1 and pulled C1 out of the office by C1's wrist; however, there were no third-party witnesses to this incident. A conflicting confidential interview indicated that C1 was verbally redirected to ask for permission before grabbing snacks, and as a result C1 threw S1's property on the ground before storming out of the office. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Center for Positive Changesfacility Number: Visit Date: 01/10/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...CONTINUED Confidential interviews indicated that S1 does not handle other clients in care in a rough manner. CCL also received the allegation that Staff (unnamed) are not addressing pests at the facility. It was reported there were cockroaches in the kitchen and staff were not addressing it. Confidential interviews indicated that cockroaches and other bugs were frequently seen in the facility kitchen, as well as in client bedrooms. Conflicting confidential interviews indicated that cockroaches were rarely seen at the facility, and the client who had cockroaches in their rooms required redirection with throwing away food. Confidential interviews indicated that staff have the kitchen treated for pests when cockroaches are seen. Confidential interviews and observations indicated that staff maintain the home to be clean and sanitary. CCL also received the allegation that Staff (S1) did not safeguard a resident's (C1) personal belonging. It was reported that S1 threw C1's phone after C1 placed their phone on S1's car. Confidential interviews indicated that S1 threw C1's phone on the pavement because of C1 tossing their phone on the hood of S1's car, and as a result C1's phone was damaged. A conflicting confidential interview indicated that S1 picked up and placed the phone on the front porch stairs leading to C1 becoming agitated. Confidential interviews indicated that C1 was later seen using their phone despite complaining about the phone being broken. CCL also received the allegation that Staff (S1) spoke inappropriately to a resident (C1). It was reported that S1 accused C1 of taking a knife out of the kitchen but then later found the missing knife in the kitchen. Confidential interviews indicated that S5, not S1, was the staff searching for the knife. Confidential interviews indicated that S5 told C1 they "know [C1] took the knife" and did not ask any other clients, despite C1 not taking things like that previously. Conflicting confidential interviews indicated that S5 brought all the clients into the game room to question them about the missing knife, as well as conduct a search of multiple clients' rooms. A confidential interview indicated that C1 was asked about the knife first due to C1 suspiciously teasing the staff while they were searching in the kitchen; however, other clients were asked as well. Confidential interviews indicated that the knife was eventually found in a location the staff previously searched. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Center for Positive Changesfacility Number: Visit Date: 01/10/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...CONTINUED Based on conflicting confidential interviews and observations, the allegations that staff handled a resident in a rough manner, staff are not addressing pests at the facility, staff did not safeguard a resident's personal belonging, and staff spoke inappropriately to a resident are unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted, and a signed copy of this report and appeal rights were provided to Amber Carter, Facility Manager. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 3 of 5

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

met_with: Amber Carter, Facility Manager


raw_content:
Narrative:
...CONTINUED Confidential interviews indicated that staff assist clients with looking for things that are missing, encourage clients not to loan each other things, hold on to expensive items for clients, and if there is a legitimate concern of clients having their money stolen, staff will recompensate clients or have current clients pay each other back. CCL also received the allegations that a staff member (S3) brandished a weapon in the presence of minor(s) (C1) in care, and that the licensee is not ensuring that residents are provided a safe environment while in care. It was reported that S3 pulled a knife to C1's side after C1 told S3 to "shut up," and that S3 continued to work in the facility after this was reported. A confidential interview indicated that S3 put a kitchen knife "pretty close" to C1's side after C1 used profanity toward S3 while helping in the kitchen; however, there were no third-party witnesses to this incident. A conflicting confidential interview indicated that C1 never became hostile or used profanity toward S3 while helping S3 in the kitchen. Confidential interviews indicted that S3 has not done anything to make other clients in care feel uncomfortable, and that other clients in care feel safe in the home. Confidential interviews indicated that S3 continued to work at the facility occasionally when assistance was needed but was moved to another of the company's facilities soon after the allegation was made regarding C1. CCL also received the allegation that a staff (S3) member antagonized minor (C1) in care. It was reported that S3 laughs at and makes sexualized comments to C1 when C1 is in the bathroom. Confidential interviews indicated that S1 and S4 would conduct safety checks when C1 locked themselves in the bathroom for an extended period and was not responding to staff asking if C1 was OK. Confidential interviews indicated that S1, not S3, made a sexualized comment to C1 when C1 refused to exit the bathroom. Conflicting confidential interviews indicated that S1 did not make sexualized comments to C1 but may have made a comment that was misinterpreted as inappropriate. Confidential interviews indicated that other clients in care have not been made to feel uncomfortable by S1. Continued... ...CONTINUED Based on conflicting confidential interviews and records reviewed, the allegations that staff are not safeguarding minor in care's belongings, staff member brandished a weapon in the presence of minor(s) in care, licensee is not ensuring that residents are provided a safe environment while in care, and staff member antagonized minor in care are unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted, and a signed copy of this report and appeal rights were provided to Amber Carter, Facility Manager.

Investigation Findings:
13On January 10, 2025, at 10: AM, Licensing Program Analyst (LPA) Jacob Salem met with Amber Carter, Facility Manager of Center for Positive Changes to deliver the findings for the above-stated allegations. LPA Salem initiated a complaint inspection at the facility on 7/05/24 at 2: PM and no immediate deficiencies were observed. During the investigation, LPA Salem interviewed Clients (C1-C5) and Staff (S1-S5). LPA Salem obtained and reviewed pertinent records. On July 3, 2024, Community Care Licensing (CCL) received an allegation that Staff (unnamed) are not safeguarding minor (C1) in care's belongings. It was reported that C1 had their things stolen by C1's roommate. A confidential interview indicated that C1 had money and electronics taken by other clients, and that staff "do not care" or try to prevent clients from stealing from each other. A conflicting confidential interview and record review indicated that C1 was recompensated for the money taken by another client, and that C1 would frequently loan out their items and money before claiming they were stolen. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Center for Positive Changesfacility Number: Visit Date: 01/10/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...CONTINUED Confidential interviews indicated that staff assist clients with looking for things that are missing, encourage clients not to loan each other things, hold on to expensive items for clients, and if there is a legitimate concern of clients having their money stolen, staff will recompensate clients or have current clients pay each other back. CCL also received the allegations that a staff member (S3) brandished a weapon in the presence of minor(s) (C1) in care, and that the licensee is not ensuring that residents are provided a safe environment while in care. It was reported that S3 pulled a knife to C1's side after C1 told S3 to "shut up," and that S3 continued to work in the facility after this was reported. A confidential interview indicated that S3 put a kitchen knife "pretty close" to C1's side after C1 used profanity toward S3 while helping in the kitchen; however, there were no third-party witnesses to this incident. A conflicting confidential interview indicated that C1 never became hostile or used profanity toward S3 while helping S3 in the kitchen. Confidential interviews indicted that S3 has not done anything to make other clients in care feel uncomfortable, and that other clients in care feel safe in the home. Confidential interviews indicated that S3 continued to work at the facility occasionally when assistance was needed but was moved to another of the company's facilities soon after the allegation was made regarding C1. CCL also received the allegation that a staff (S3) member antagonized minor (C1) in care. It was reported that S3 laughs at and makes sexualized comments to C1 when C1 is in the bathroom. Confidential interviews indicated that S1 and S4 would conduct safety checks when C1 locked themselves in the bathroom for an extended period and was not responding to staff asking if C1 was OK. Confidential interviews indicated that S1, not S3, made a sexualized comment to C1 when C1 refused to exit the bathroom. Conflicting confidential interviews indicated that S1 did not make sexualized comments to C1 but may have made a comment that was misinterpreted as inappropriate. Confidential interviews indicated that other clients in care have not been made to feel uncomfortable by S1. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Center for Positive Changesfacility Number: Visit Date: 01/10/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...CONTINUED Based on conflicting confidential interviews and records reviewed, the allegations that staff are not safeguarding minor in care's belongings, staff member brandished a weapon in the presence of minor(s) in care, licensee is not ensuring that residents are provided a safe environment while in care, and staff member antagonized minor in care are unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted, and a signed copy of this report and appeal rights were provided to Amber Carter, Facility Manager. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 3 of 3

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


summary: Facility Evaluation

raw_content:
Narrative:
On 06/07/2021 at 9: A.M., Licensing Program Analyst (LPA) Marisol Lopez conducted a required annual inspection at the facility above. LPA met with Administrator Robyn Reyes who led the tour of Center for Positive Changes. LPA inspected the facility interior and exterior. There were six male clients residing at this facility. The facility is a two-story residence with three bedrooms, three bathrooms, two living rooms, one upstairs and one downstairs, a dining room, second floor den, kitchen, walk-through pantry area, upstairs hallway with two storage closets, first floor laundry room, 2 staff offices, therapy room and 2-car garage. The facility has been operating with a capacity of six males from ages 13 years old to 17 years old and non-minor dependents. Currently there are six children in care. Bedrooms are arranged so that no more than two children share a room and each bedroom includes adequate drawers and closet space for two children's belongings. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. Licensee maintains an adequate supply of perishable and non-perishable foods and appears to be following the posted menu. All required forms are posted including the Grievance Procedures, Visitation Policies, and Personal Rights form. Medications are locked and centrally stored in a locked cabinet in the staff office. Licensee has provisions for contraceptives to be held in individually locked containers by clients. Individual beds were observed with appropriate clean linens, pillows, comforters, and mattresses in good repair. The hot water in the client's bathroom was measured to be 117.0 degrees. Per facility staff, no firearms or weapons are allowed in the facility. Facility appears to be meeting the terms and conditions of their license. Licensee has obtained National Accreditation through CARF and the Accreditation is valid through August 2022. LPA discussed the following with the Administrator: Incident reporting, including incidents related to Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. Personnel Files are maintained off-site and transported to LPA within reasonable time. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. A review of client records was also completed on this date including the Medication Administration Record (See Confidential Name List- LIC 811 dated on June 07, 2021). Personnel files were reviewed to ensure they contained all required documentation. Children and staff records are organized. Staff's CPR and First Aid card were current. Child's records contain original needs and services plan signed by the child and their authorized rep. Child's records contain authorization for emergency medical care signed by each child's authorized rep. Licensee has a current needs and services plan for each resident on file. Facility personnel meet staff training requirements Administrator Robyn Reyes is present at the facility a minimum of 20 hours a week, as verified by staff schedule and interviews. Appropriate staff/client ratios were verified during this inspection. Based on observations made during the inspection, no deficiencies observed during today's visit. An exit interview was conducted and this report was reviewed with Administrator Robyn Reyes and a copy of this report was provided.

met_with: Robyn Reyes


summary: Facility Evaluation

raw_content:
Narrative:
On May 24, 2023, at 8: AM, Licensing Program Analyst (LPA) Gloria Meza-Gonzalez conducted an inspection at the facility above. LPA Meza-Gonzalez met with Program Manager (PM) Paul Kelley, Residential Director (RD) Robyn Reyes, and Facility Manager (FM) D'Andre James. The purpose of the inspection is to conduct a random annual inspection. The facility is licensed for six male youths with an age range of 14 to 17 years old as well as non-minor dependents. There are five youths in care. There were three youths present at the time of the inspection. LPA Meza-Gonzalez toured the facility with FM James. LPA Meza-Gonzalez inspected the facility's interior and exterior. The facility is a two-story residence with three bedrooms and three bathrooms. The first floor is set up as follows: The staff office, cleaning supply closet, laundry room, storage closet, garage, living room, bathroom, and bedroom. The medications and client files are kept in a locked cabinet in the locked staff office. The cleaning supplies are kept in a locked closet. The second closet has extra bedding and linen. The therapy office has two desks, two chairs, phones, and computers. The therapy office is locked when not in sure. Bedroom #1 has adequate drawers, closet space for two children's belongings, and two twin beds. One client per bed. The clients share the bathroom. The garage is a recreation area that has weights and a pool table for clients' use. There is also a deep freezer to store extra food. The second floor has two living rooms, a kitchen, a dining room, a closet with games, two bedrooms, two bathrooms, and two balconies. The two livings have two couches and two TVs. LPA Meza-Gonzalez observed the kitchen has two days of perishable and seven days of nonperishable foods. In the dining room, there is a table with six chairs. Bedroom #2 has adequate drawers, closet space for two children's belongings and two twin beds. One client per bed. The clients share the bathroom in the hallway. Bedroom #3 has adequate drawers, closet space for two children's belongings and two twin beds. One client per bed. The clients share the bathroom. There is a closet between Bedroom #2 and Bedroom #3 that has games for clients' use. See LIC809C page 2. LPA Meza-Gonzalez observed seven smoke detectors and carbon monoxide detectors in the facility. The smoke and carbon monoxide was tested and was observed to be in working order. The facility has two fire extinguishers. The two fire extinguishers are properly charged and serviced. Facility grounds are clean and free of debris and observable hazards. All required forms are posted including the Grievance Procedures, Visitation Policies, Menu, and Personal Rights. The hot water in the client's bathroom was measured to be 120.0 degrees. Per facility staff, no firearms or weapons are allowed in the facility. The facility appears to be meeting the terms and conditions of its license. Licensee has obtained National Accreditation through CARF and the Accreditation is valid through August 31, 2025. LPA Meza-Gonzalez discussed the following with RD Reyes and PM Kelley: Incident reporting, including incidents related to Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. Personnel Files are maintained off-site and transported to LPA Meza-Gonzalez within 30 minutes. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. A review of client records was also completed on this date including the Medication Administration Record (See Confidential Name List- LIC 811 dated May 24, 2023). Personnel files were reviewed to ensure they contained all required documentation. Children and staff records are organized. The staff's CPR and First Aid cards were current. The clients' records contain the original needs and services plan signed by the child and their authorized representative. The clients' records contain authorization for emergency medical care signed by each child's authorized representative. Licensee has a current needs and services plan for each resident on file. Facility personnel meets staff training requirements. Based on observations made during the inspection, no deficiencies were observed during today's visit. An exit interview was conducted and this report was reviewed with RD Reyes and a copy of this report was provided.

met_with: Paul Kelley and Robin Reyes


summary: Facility Evaluation

raw_content:
Narrative:
On August 15, 2025 at 10: AM, Licensing Program Analyst (LPA) Jacob Salem conducted an announced visit to the above facility and met with Amber Carter, Facility Manager for the purpose of conducting an annual inspection. LPA reviewed five client files (C1-C5), which are kept locked in the staff office. The client files reviewed contained the required information and records, including pre-placement screenings, personal rights and facility policy acknowledgements, and medication logs. LPA inspected the facility's physical plant, including personal rights postings, health related services, buildings and grounds, food services, indoor and outdoor activity space, and furniture, fixtures, equipment and supplies. The home is clean, in good repair, and free from observable risks to clients' health, safety, and personal rights. The home is a two story building with three client bedrooms and three client bathrooms which are set up as follows: Bedroom #1 downstairs has two twin beds and currently sleeps two clients, bedroom #2 has two twin beds and currently sleeps one client, and bedroom #3 has two twin beds and currently sleeps two clients. There is a kitchen, two living rooms living room, staff office and storage closets, therapy office, and backyard/patio. LPA conducted two staff interviews. Due to time constraints, the annual is being extended to conduct a review of staff files and interview clients. An exit interview was conducted and a signed copy of this report was provided to Amber Carter, Facility Manager.


summary: Facility Evaluation

raw_content:
Narrative:
On August 18, 2025 at 9: AM, Licensing Program Analyst (LPA) Jacob Salem conducted an announced visit to the above facility and met with Amber Carter, Facility Manager. The purpose of this Case Management inspection is to conduct an annual continuation from 8/15/2025. LPA reviewed five staff files (S1-S5), at the facility's corporate office. The staff files reviewed contained the required information and records, including the required clearances and health screenings, hiring paperwork and qualifications, and on-boarding trainings. LPA conducted two client interviews at the facility. Based on observations made during the inspection, there were no deficiencies cited at this time. An exit interview was conducted with Amber Carter, Facility Manager and a signed copy of this report was provided.


raw_content:
Narrative:
LPA Kinder conducted 1 confidential interview on 08/11/22. LPA Carmona conducted 13 confidential interviews and attempted 3 between 09/02/22- 11/09/22. Based on interviews conducted during the investigation process the allegation staff left minor unsupervised in a car for extended periods of time cannot be substantiated because statements made during a confidential interview conducted on 11/01/22 did not corroborate with the statement made during a confidential interview conducted on 11/08/22. In addition, LPA Carmona attempted and was unable to interview 2 of the 3 clients placed during the time frame the complaint was made. The confidential interview on 11/01/22 was unable to identify staff member who had left a minor unsupervised in car for an extended period of time. The confidential interview on 11/01/22 was consistent with the transportation logs dated 08/15/22 which documented a dentist appointment where two clients were transported. The staff member who initialed the transportation log stated they do not remember details of the transportation on 08/15/22. LPA Carmona received documentation of the dentist appointment which makes the statement given on 11/01/22 inconsistent. Lastly, 1 confidential interview conducted on 11/01/22 disclosed a minor being left in a car and 9 confidential interviews conducted from 8/11/22-11/09/22 denied the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated An exit interview was conducted. A copy of this report and the Appeal Rights were provided via e-mail to Administrator, Staci Exceus.

Investigation Findings:
13On 11/10/22 at 10:10 a.m. Licensing Program Analyst (LPA) Jacqueline Carmona conducted a complaint inspection to the above Short Term Residential Therapeutic Program (STRTP) and met with Administrator, Staci Exceus for the purpose of delivering findings. During the investigation, LPA Carmona reviewed the agency's file at the licensing office, including the complaint history, criminal background check, incident reports and facility personnel report summary. LPA Kinder obtained four minors needs and services plans, LIC500, LIC9020, Center for Positive Changes Therapeutic Level System, the facility Program Statement Section 3 on Transportation. LPA Carmona obtained outing receipts for the months of July 2022, August 2022, and September 2022. Transportation logs for facility vehicles for the months of July 2022, August 2022, and September 2022 and email verification of a dental appointment. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Jacqueline Carmona LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: CENTER FOR POSITIVE CHANGESFACILITY NUMBER: VISIT DATE: 11/10/2022

met_with: Administrator, Staci Exceus.


raw_content:
Narrative:
Based on interviews conducted during the investigation process on the above allegations cannot be substantiated because statements given in 8 of the 14 confidential interviews conducted from 12/02/22 - 2/23/23 corroborated that the staff in the facility properly supervise the clients in care. 3 of the 14 confidential interviews conducted from 12/19/22- 1/19/23 corroborated that staff spends their time in the administrative office and is not properly supervising clients in the facility. In addition, the allegation reporting requirement cannot be substantiated because the administrator denied the allegation and stated they were having internet issues. 7 confidential interviews conducted from 12/08/22-2/23/23 corroborated the facility staff reports all incidents to CCL. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted. A copy of this report and the Appeal Rights were provided to the Agency Director .

Investigation Findings:
13On 2/28/23 at approximately 1:40 p.m. Licensing Program Analyst (LPA) Jacqueline Carmona conducted a complaint inspection to the above Short Term Residential Therapeutic Program (STRTP) and met with Agency Director Shavonne Powell for the purpose of delivering findings. During the investigation, LPA Carmona reviewed the agency's file at the licensing office, including the complaint history, criminal background check, incident reports dated 11/23/22 and 11/17/22, LIC500, LIC9020, SCAR report dated 11/17/22, email dated 12/08/22, case notes for two clients from August 2022 through December 2022. In addition, LPA Carmona reviewed two minors needs and services plans dated 12/21/22 and 10/11/22 and a CFT meeting sign in document dated 12/21/22. LPA Carmona conducted 14 interviews from 12/01/22- 2/23/23 and 1 attempted interview on 1/19/23. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Jacqueline Carmona LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: CENTER FOR POSITIVE CHANGESFACILITY NUMBER: VISIT DATE: 02/28/2023

met_with: Shavonne Powell, Agency Director


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
minor was not provided with school supplies is substantiated because statements given during 4 confidential interviews confirmed that the facility did not provide a client with school supplies. In addition, documentation was obtained which corroborated that minor was not provided with school supplies. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, ILS 87088 (i), are being cited on the attached LIC 9099D.") An exit interview was conducted. A copy of this report and the Appeal Rights were provided to the Administrator. Based on interviews conducted during the investigation process the allegations above cannot be substantiated because there were conflicting statements given in the 17 confidential interviews conducted from 1/19/23- 4/10/23. Incident reports reviewed by LPA Carmona from 10/08/22-12/21/22 also conflicted with statements given during the confidential interviews conducted. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted. A copy of this report and the Appeal Rights were provided to the Administrator.

Investigation Findings:
13On 4/21/23 at approximately 10:52 a.m. Licensing Program Analyst (LPA) Jacqueline Carmona conducted a complaint inspection to the above Short Term Residential Therapeutic Program (STRTP) and met with Administrator, Staci Exceus for the purpose of delivering findings. During the investigation, LPA Carmona reviewed the agency's file at the licensing office, including the complaint history, criminal background check, case notes dated December 2022, daily safety check form, and daily communication logs for the months of December 2022 and January 2023. In addition, LPA Carmona reviewed incident reports dated 10/08/22-12/21/22, needs and services plans dated 12/21/22 and 1/17/23, email dated 2/10/23. LPA Carmona conducted 17 interviews from 1/19/23- 4/10/23 and 2 attempted interviews on 1/19/23 and 2/21/23. Based on interviews conducted and documents obtained during the investigation process the allegation SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Jacqueline Carmona LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: CENTER FOR POSITIVE CHANGESFACILITY NUMBER: VISIT DATE: 04/21/2023

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

met_with: Staci Exceus, Administrator


raw_content:
Narrative:
Based on interviews conducted during the investigation process the allegations above cannot be substantiated because there were conflicting statements given in the 11 confidential interviews conducted from 1/26/23 - 4/04/23. In addition, documents obtained by LPA Carmona and client's personal property and valuables (LIC 621) conflicts with the statements made during 4 confidential interviews conducted on 2/02/23 and 4/04/23. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted. A copy of this report and the Appeal Rights were provided to the Administrator.

Investigation Findings:
13On 4/23/ at approximately 10:52 a.m.Licensing Program Analyst (LPA) Jacqueline Carmona conducted a complaint inspection to the above Short Term Residential Therapeutic Program (STRTP) and met with Administrator, Staci Exceus for the purpose of delivering findings. During the investigation, LPA Carmona reviewed the agency's file at the licensing office, including the complaint history, criminal background check, incident report dated 1/30/23, an email dated 1/31/23. In addition, LPA Carmona reviewed client's needs and services plan dated 12/21/22 and personal property and valuables (LIC621). LPA Carmona conducted 11 interviews from 1/26/23- 4/04/23 and 3 attempted interviews on from 2/21/23-2/28/23. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Rosa Rodriguez LICENSING EVALUATOR NAME: Jacqueline Carmona LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: CENTER FOR POSITIVE CHANGESFACILITY NUMBER: VISIT DATE: 04/21/2023


summary: Facility Evaluation

raw_content:
Narrative:
On 5/24/2021 at 8:50am Licensing Program Analyst (LPA) N. Sanders arrived at the above facility for the purpose of conducting a pre licensing inspection. LPA met with Stacy Exceys, facility Administrator and inspected the facility inside and out. The facility has a provisional license for six clients. There are four clients in care right now. The facility is clean and free of clutter. Kitchen is clean, sanitary and in good repair. Knives, sharp objects and cleaning supplies are locked. Facility has adequate amount of cooking and dishware supplies. Menu is posted. Water temperature measures 98F. Dining area has enough space for capacity. There are two days of perishable and seven days of non-perishable food. Additional fridge is located in the garage with more food supplies. Living room has a seating capacity for clients and staff. Furniture is in good repair. Activity area has age appropriate activities for population served. Floors are clean and in good repair. Windows have screens and blinds. There are four bedrooms in this facility. At this time there is one client for each bedroom. All bedrooms are specious enough to walk through and accommodates the required bedroom furniture. Each bedroom has lamps, a dresser and a closet space. Beds are in good repair, with good springs, clean mattresses, pillows, fitted sheets, flat sheets and blankets. Windows have screens and blinds. There are four bathrooms in this facility. Carbon monoxide detectors and smoke detectors meet standards. Fire extinguishers are up to date. Facility has enough supplies for linen, towels and a working phone for clients to make calls. Facility has a van and a car for transportation. Both vehicles were inspected and are in working condition. Both vehicles are insured and has renewed registration. Documents are in the car. Medications are located in staff room alongside with client files. Staff files are located in corporate office located in Sacramento, CA. Staff room is inaccessible to clients. First Aid Kit is complete. Medications are stored separately from toxins. Medication administration records being used. License, Foster Youth Personal Rights, Facility Sketch are posted in the entry room. There are cameras installed in common areas. The backyard is small and free of clutter. There are some chairs and a BBQ grill in the backyard. There are no bodies of water in this facility. LPA reviewed four clients files. Files have all required documents in them: Personal Rights signed by clients, Admission agreement, Medical Assessment, Appraisal and Needs and Services Plans, Safeguards and Cash Resources Information. Consent forms are signed and dated. Facility employees 15 staff including administrator and on call staff. LPA reviewed five staff files. Staff files have : First Aid Training Records, Training Records show required training hours for each staff, Criminal Records Statement and Clearances, Personal information alongside with Job Application, Medical History and TB test, Education Verification documents and signed Employee Rights. No title 22 regulations were cited on today's visit. A copy of this report was left with Stacy Exceys, Administrator.

met_with: Stacy Exceys, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 7/21/ Licensing Program Analyst (LPA) N. Sanders contacted the above facility to conduct virtual case management/incident report. Case management was generated from an incident report received by Sacramento Regional Office on 7/16/2021. LPA and facility representatives discussed one particular incident as well as clients running away frequently from the facility. It was discussed what can the facility do to support clients and avoid run-away behavior. Interviews were conducted. No citations were issued during today's visit. A copy of this report was emailed to Staci Exceus, Facility Administrator.

met_with: Staci Exceus, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 7/27/2021 at 11:45am Licensing Program Analyst (LPA) N. Sanders arrived at the above facility for the purpose of conducting case management/incident report. LPA met with Renee Robinson, Assistant Manager and discussed the incident. Sacramento Regional Office (RO) received an incident report on 7/26/2021 stating one client not having the inhaler. Client ended up in the hospital and was released the same day to facility staff. Inhaler and other medications were prescribed and given to facility staff. LPA reviewed client's file. Interviews with staff and client were conducted. Advisory Note (AN) was given to the facility. No title 22 regulations were cited on today's visit. A copy of this report was emailed to Staci Exceus.

met_with: Renee Robinson, Assistant Manager


summary: Facility Evaluation

raw_content:
Narrative:
On October 12, 2021 at 10:30 am Licensing Program Analyst (LPA), Yuvi Diaz made an unannounced visit to conduct a case management regarding an incident report received by The Department on 10/06/21 regarding Lack of Supervision. LPA met with Trayvon Kennedy, Facility Manager (who assisted with the inspection). STRTP is a two story home it consists of two living spaces, one dinning room, one kitchen, four bedrooms, 2.5 bathrooms, laundry room, and large office room for therapist and rehabilitation specialist. LPA conducted interviews with facility manager, one staff member, one client decline to interview, and gathered information about the former staff members. Documentation gathered: NSP Staff Roster Cient Face sheet Client Roster An exit interview was conducted at 12:15 pm with Trayvon Kennedy and a copy of this report will be emailed to Administrator Staci Exceus This case management investigation needs further investigation.

met_with: Trayvon Kennedy


facility_name: CENTER FOR POSITIVE CHANGES 2

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
Confidential interviews provided consistent statements of bubble pack containing psychotropic medication missing pills. Record review was unable to determine what had happened to the medication. Both confidential interviews and record review revealed an internal investigation was completed regarding the missing medication and was unsuccessful in determining what happened to the medication. Based on confidential interviews and record review, there is sufficient evidence to support that staff mismanaged youth's medication. The complaint is valid because the preponderance of evidence standard has been met. The facility is being cited for violation of Interim Licensing Standards (ILS) standard 87070(b)(14)(F-H). CHILDREN'S RECORDS 87075(B)(14) a separate log for each psychotropic mediation prescribed to a child documenting tall of the following: (F) The date and time of each dose taken by the child, (G) Documentation of each refusal, (H) Staff initials for each time a psychotropic medication is taken by a child, as an indication that they supervised the child self-administering their psychotropic medication. A copy of this report, including appeal rights, was discussed with and provided to Maria Alonso, Administrator of Center for Positive Change STRTP.

Investigation Findings:
13On October 22, 2025, at 10:15 a.m., Licensing Program Analyst (LPA) Jacob Ortega met with Administrator Maria Alonso Center for Positive Change Short-Term Residential Therapeutic Program (STRTP), to deliver the finding for the above-stated allegation. A Health and Safety inspection was conducted on April 21, 2025, and no immediate health or safety hazards were observed at that time. The investigation was conducted by LPA Jacob Salem and LPA Ortega and included interviews with four staff (S1,S2,S5,S6), four clients (C1-C4), county social worker (CSW3), and probation officer (PO). Additionally, county, facility, and client records were reviewed. On April 14, 2025, Community Care Licensing (CCL) received a complaint alleging that staff mismanaged a youth's medication. Specifically, it was reported a review of facilities psychotropic medication logs and corresponding psychotropic bubble packs for the month of April 2025 revealed medication was missing and there waws no documentation to account for missing medication. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Nicole Strickland LICENSING EVALUATOR NAME: Jacob Ortega LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: CENTER FOR POSITIVE CHANGES 2FACILITY NUMBER: VISIT DATE: 10/22/2025

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

met_with: Administrator Maria Alonso

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
On February 25, 2025, at 10: AM, Licensing Program Analyst (LPA) Jacob Salem met with Amber Jansen, Chief Operations Officer (COO) of Center for Positive Changes for the purpose of conducting a pre-licensing inspection for a Short Term Residential Treatment Program. Center for Positive Changes is applying for a license for six ambulatory children and Non-Minor Dependents. The home is a two story residence located on a residential street. LPA and COO Jansen toured the home inside and out. The home is currently empty and partially unfurnished due to the licensee's current facility still utilizing the furniture and other supplies. LPA observed the applicant's current facility to be in compliance and contain all the necessary provisions, such as bedding and storage closet for files and medications, and COO Jansen stated that all furniture and equipment currently in use will be brought to the new home upon relocating with the clients in care. The current home contains a kitchen, two living rooms, garage, backyard and therapy offices, and staff office where client files and medications will be stored. The license, LIC 610C, and Personal rights will be posted in the entrance upon the clients relocating to the home. The bedrooms will be set up as follows: - Bedroom 1: sleeping two clients downstairs - Bedroom 2: sleeping one client downstairs - Bedroom 3: sleeping one client downstairs - Bedroom 4: sleeping two clients upstairs The client bedrooms will have ample lighting and adequate storage space for clothing and personal belongings. The applicant has working and recently inspected fire extinguishers and a first-aid kit. The kitchen contains working and clean appliances for food preparation, storage, and cleaning. Continued... ...CONTINUED There were no safety or health hazards observed during the walk though of the home and property. There is a central heating/air conditioning unit in the home located downstairs and the home is kept at a comfortable temperature. Client bathrooms are clean and appliances are in working order and sinks were tests to run at 116.6 and 119.7 degrees F. Windows and screens were inspected and are in good repair. The facility has demonstrated compliance with Title 22, Division 6 of the California Code of Regulations and Interim Licensing Standards. An exit interview was conducted and a copy of this report was provided to Amber Jansen, Chief Operations Officer of Center for Positive Changes.

visit_type: Prelicensing

met_with: Amber Jansen, Chief Operations Officer


summary: Facility Evaluation

raw_content:
Narrative:
On April 10, 2025 at 10: AM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced visit to the above facility for the purpose of conducting an post-licensing inspection and met with Kendrick Johnson, Facility Manager. LPA reviewed the facility's emergency disaster plan and provisions. LPA inspected the facility's physical plant, including personal rights postings, health-related services, buildings and grounds, food services, indoor and outdoor activity space, and furniture, fixtures, equipment and supplies. The home is clean, in good repair, and free from observable risks to clients' health, safety, and personal rights. The home is a two story building with four client bedrooms and two client bathrooms which are set up as follows: bedroom #1 sleeps two clients downstairs, bedroom #2 sleeps one client downstairs, bedroom #3 sleeps one client downstairs, bedroom #4 sleeps two clients upstairs. There is a kitchen and living room, seperate office in backyard for therapy and visitation, staff office and storage closets, and backyard/patio. LPA conducted one staff and one client interview. Due to time constraints, the inspection is being extended to conduct a file reviews and complete staff and client interviews. An exit interview was conducted and a signed copy of this report was provided to Kendrick Johnson, Facility Manager.

met_with: Kendrick Johnson, Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On April 14, 2025 at 10: AM, Licensing Program Analyst (LPA) Jacob Salem conducted an announced visit to the above facility and met with Maria Alonso, Administrator. The purpose of this Case Management inspection is to conduct an annual continuation from 4/10/2025. LPA reviewed five staff files (S1-S5) at the facility's corporate office, which were provided upon request for review. The files contained all of the required demographic and background information, staff qualifications, proof of criminal background clearances, and medical screenings at hire. LPA reviewed five client files (C1-C5) which are kept confidential in a locked staff closet and contained all of the required demographic information, pre-placement screenings and appraisals, needs and services plans, and records of client cash resources. LPA conducted one staff and one client interview. Based on observations made during the inspection, there were no deficiencies cited at this time. An exit interview was conducted with Maria Alonso, Administrator and a signed copy of this report was provided.

met_with: Maria Alonso, Administrator


summary: Complaint Investigation - Substantiated - 3 allegations

raw_content:
Narrative:
...CONTINUED A review of video and photo evidence revealed that S1 bit C1 during a physical altercation at night outside, while C1 was holding S1 down. Confidential interviews yielded conflicting information regarding how the altercation began and S1's conduct during the incident. One confidential interview indicated that S1 was acting in self-defense during the altercation and used the minimum amount of force to protect themself and get away. Conflicting confidential interviews indicated that S1 engaged with C1 aggressively during the incident. Confidential interviews indicated that S1 has a history of not utilizing trauma-informed care practices with clients. Based on confidential interviews and records reviewed, the allegations that staff handled a minor in a rough manner and staff bit minor in care are substantiated because the preponderance of evidence has been met. This posed an immediate Health, Safety, or Personal Rights risk to children in care, and the facility will be cited for violating Interim Licensing Standards for Short Term Residential Treatment Programs, Sections 87072(c)(1) and 87072(c)(16). An exit interview was conducted, and a plan of correction was developed with Kendrick Johnson, Facility Manager. A copy of this report, appeal rights, and LIC 811 were provided to Kendrick Johnson, Facility Manager.

Investigation Findings:
13On December 4, 2025, at 12: PM, Licensing Program Analyst (LPA) Jacob Salem met with Kendrick Johnson, Facility Manager of Center for Positive Changes 2 (CFPC) to deliver the findings for the above-stated allegations. LPA Salem initiated a complaint inspection at the facility on 5/12/2025 at 9: AM and no immediate deficiencies were observed. During the investigation, LPA Salem interviewed Clients (C1-C5), Staff (S1-S6), two relatives, and a county social worker. Pertinent records were obtained and reviewed. On May 2, 2025, Community Care Licensing (CCL) received the allegations that staff (S1) handled a minor (C1) in a rough manner and that staff (S1) bit a minor (C1) while in care. It was reported that staff (S1) placed their hands around C1's neck, and once C1 was able to move away from S1, the situation escalated into a physical altercation during which C1 was bitten by S1. It was further reported that C1 was admitted to a psychiatric hospital following the incident due to being considered a danger to others. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: CENTER FOR POSITIVE CHANGES 2FACILITY NUMBER: 374690099

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


raw_content:
Narrative:
...CONTINUED Confidential interviews indicated that C1 had been accused of stealing from peers, which led to their sudden escalation and assault on C2. Confidential interviews indicated that staff were present during the incident and followed their emergency intervention plan, including verbal de-escalation and notifying law enforcement. A confidential interview indicated that C1 and C2 had argued earlier in the day and openly planned to fight in front of staff, but staff did not ensure the clients were separated or take preventative measures. Conflicting confidential interviews indicated that the clients had not planned to fight and appeared to be getting along prior to the incident. Confidential interviews indicated that the attack on C2 by C1 was unexpected, and that C1 has a history of sudden escalations. Based on conflicting confidential interviews, the allegation that staff did not intervene between a physical altercation with minors is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted with Kendrick Johnson, Facility Manager and a copy of this report and appeal rights were provided.

Investigation Findings:
13On December 18, 2025, at 4: PM, Licensing Program Analyst (LPA) Jacob Salem met with Kendrick Johnson, Facility Manager of Center for Positive Changes 2 to deliver the finding for the above-stated allegation. LPA Salem initiated a complaint inspection at the facility on 9/19/2025 at 2: PM and no immediate deficiencies were observed. During the investigation, LPA Salem interviewed Clients (C1-C3), Staff (S1-S4), and a county social worker. Pertinent records were obtained and reviewed. On September 16, 2025, Community Care Licensing (CCL) received the allegation that staff (S1 and S2) did not intervene between a physical altercation with minors (C1 and C2). It was reported that C1 attacked C2 while staff verbally intervened and called 911, which resulted in C1 being arrested and C2 sustaining a head injury requiring staples. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # San Diego, CA Facility Name: Center for Positive Changes 2facility Number: Visit Date: 12/18/ Narrative 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32...CONTINUED Confidential interviews indicated that C1 had been accused of stealing from peers, which led to their sudden escalation and assault on C2. Confidential interviews indicated that staff were present during the incident and followed their emergency intervention plan, including verbal de-escalation and notifying law enforcement. A confidential interview indicated that C1 and C2 had argued earlier in the day and openly planned to fight in front of staff, but staff did not ensure the clients were separated or take preventative measures. Conflicting confidential interviews indicated that the clients had not planned to fight and appeared to be getting along prior to the incident. Confidential interviews indicated that the attack on C2 by C1 was unexpected, and that C1 has a history of sudden escalations. Based on conflicting confidential interviews, the allegation that staff did not intervene between a physical altercation with minors is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted with Kendrick Johnson, Facility Manager and a copy of this report and appeal rights were provided. SUPERVISORS NAME: Dawn Segura LICENSING EVALUATOR NAME: Jacob Salem LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) - (06/04)Page: 2 of 2

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


summary: Facility Evaluation

raw_content:
Narrative:
On February 06, 2026, Licensing Program Analyst (LPA), Cynthia Robinson, met with Facility Manager, Kendrick Johnson, and conducted an unannounced inspection at the facility. The purpose of the inspection was to conduct a confidential interview (see confidential names list LIC 811 dated February 06, 2026) regarding a previous placement. An exit interview was conducted. A copy of the LIC 809 and LIC 811 was provided to Kendrick Johnson.

met_with: Facility Manager, Kendrick Johnson


summary: Facility Evaluation

raw_content:
Narrative:
On March 12, 2026, at 1: PM, Licensing Program Analyst (LPA) Jacob Salem, Licensing Program Manager (LPM) Dawn Segura, and Regional Manager (RM) Natasha Dunlap conducted an office meeting virtually, via Teams, with Center for Positive Changes Chief Operating Officer (COO) Amber Jansen. The purpose of the meeting was to discuss and review two substantiated Type A complaints against the facility and the extension of the facility's provisional license. RM Dunlap informed the licensee that the facility's provisional license would be extended six months to ensure the facility remains in compliance prior to a permanent license being issued. During the meeting, COO Jansen was provided information on the Department's Technical Support Program. A copy of this report was sent to COO Amber Jansen for signature. The original signed copy will be maintained in the facility file in the San Diego Regional Office.

met_with: Amber Jansen, Chief Operating Officer


facility_name: CENTER FOR POSITIVE CHANGES 3

raw_content:
Narrative:
Based on interviews and information gathered during the investigation, the preponderance of evidence standard has been met and the Department has determined the allegations that there is mold in the upstairs bathroom and that railing that leads to the second floor is unstable and in disrepair are substantiated. This posed a potential health and safety risk to the children placed in care. The STRTP is being issued a citation for violations of the Interim Licensing Standards, Chapter 7.5, Version 3, Sections 87087(a) Buildings and Grounds. See attached LIC 9099D for cited deficiency. An exit interview was conducted, and a copy of the report and appeal rights were emailed for signatures. Original signed reports will be placed in facility file. asleep during the night shift. According to confidential information received during interviews, some staff might briefly close their eyes to "rest them," which might have been mistaken for actually being asleep. While other confidential information received by Licensing Office stated that allegations had occurred, and that staff sometimes "pick on" and yell at some of the clients in a way that is disrespectful. Confidential information received also stated that some of the staff sometimes falls asleep to the point of snoring during the night shift. LPA received inconsistent information regarding the allegations. Based on confidential interviews and information obtained, the allegations that staff members do not threat clients with respect, and that the night staff falls asleep while on duty, may have occurred, however is not supported or proven by evidence. Therefore, the above allegations are unsubstantiated at this time. Exit interview was conducted and a copy of this report was provided.

Investigation Findings:
13LPA Mena met with Facility Manager, Maria Alonso to discuss the investigative findings for the above stated allegations. An investigation was conducted by LPAs Ann Valenzuela and Daniel Mena regarding allegations. LPA Valenzuela conducted an inspection to the Sort Term Residential Therapeautic Program (STRTP) on March 11, 2021 at 11:30am. LPAs interviewed five staff (S1, S2, S3, S4 & S5), four foster children (C1, C2, C3 & C4), as well as reviewed client and facility records. Community Care Licensing received information on March 01, 2021 alleging that there is mold in the upstairs bathroom and that railing that leads to the second floor is unstable and in disrepair. Information received in confidential interviews corroborated allegation with a preponderance of evidence. According to confidential interviews, it was confirmed that there was mold in the upstairs bathroom shower area at the time that the complaint was made, which was photographed and had since been cleaned by a hired cleaning person. Confidential interviews and LPA Valenzuela's observations also confirmed that there were several spindles missing from the upstairs railing. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Daniel Mena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: CENTER FOR POSITIVE CHANGES 3FACILITY NUMBER: VISIT DATE: 09/24/2021

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

met_with: Maria Alonso


raw_content:
Narrative:
Other confidential interviews stated that the allegations were true. LPA was unable to interview C1 as C1 refused to be interviewed at this time. The interviews that were provided to the LPA were not consistent regarding the allegations. Based on interviews and record reviews the allegations that staff denied C1 a self-pass, staff did not ensure that C1's clothing needs were met, and staff did not ensure that C1 was adequately fed, may have occurred, however is not supported or proven by evidence. Therefore, the allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Ms. Alonso.

Investigation Findings:
13On December 16, 2021 at 9:48am Licensing Program Analyst (LPA) Daniel Mena conducted an unannounced inspection to the facility to deliver the findings of the above allegations. LPA met with Facility Manager, Maria Alonso. LPA Ann Valenzuela conducted a tele-inspection of the facility on April 02, 2021 at 3:15 am and no immediate deficiencies were observed. LPA Darlene Almaraz-Oseguera conducted the investigation. Four of five children (C1, C2, C3, C4, C5), three staff and facility administrator were interviewed. It was reported to Community Care Licensing (CCL) that staff denied C1 a self-pass, staff did not ensure that C1's clothing needs were met, and staff did not ensure that C1 was adequately fed. Confidential staff interviews reported that due to COVID19, the clients were not given self-passes but continued to have family passes. Confidential staff interviews reported that staff took the clients including C1 to Target and Walmart to get anything the clients needed. However staff was not taking the clients to the mall during the pandemic. Additional confidential interviews reported that the kitchen is closed at 9:00pm and the clients can eat snacks or use the microwave but there is no cooking after 9:00pm. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Natasha Dunlap LICENSING EVALUATOR NAME: Daniel Mena LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: CENTER FOR POSITIVE CHANGES 3FACILITY NUMBER: VISIT DATE: 12/16/2021

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


raw_content:
Narrative:
Confidential interviews stated there was an altercation between C1 and C2 at school that received media attention however, the facility staff were informed of the incident by the sheriff's department and there was no outside communication of the incident. Confidential interviews stated facility staff are trained on how to handle media attention and staff did not communicate with any activists or media. Confidential interviews stated staff are not aware of any staff breaching confidentiality however, media attempted to reach facility staff for information. Confidential interviews stated the facility staff did not breach confidentiality of any client however, other information provided alleged the allegation occurred. Based on confidential interviews, the allegation that the facility staff breached confidentiality of client in care may have occurred, however are not supported or proven by evidence. Therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this signed report was emailed to Facility Administrator Anne Ford.

Investigation Findings:
13On August 31, 2022, at 9:00 a.m. Licensing Program Analyst (LPA) Marisol Lopez arrived at the facility unannounced and met with Facility Administrator Anne Ford of Center for Positive Changes 3 to discuss the investigative findings for the allegation noted above. On September 16, 2021 at 11:40 a.m, Licensing Program Analyst (LPA) Marisol Lopez met with Facility Manager Maria Alonso conduct an unannounced initial complaint investigation. LPA conducted a safety inspection and no deficiencies were observed at that time. During the investigation, LPA conducted confidential interviews with one program administrator, two staff (S1-S2), one of two clients (C1-C2) and reviewed incident report. On September 09, 2021, the Department received an allegation that Facility staff breached confidentiality of client in care. It was reported that a community activist was contacted by a client's guardian and it was unknown what specific confidential information was disclosed. (see continuation LIC9099-C dated 08/31/22) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Marisol Lopez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, METROPOLITAN DR. # FACILITY NAME: CENTER FOR POSITIVE CHANGES 3FACILITY NUMBER: VISIT DATE: 08/31/2022

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

met_with: Anne Ford


raw_content:
Narrative:
Confidential interviews stated staff verbally encourage C1 to make positive choices, staff remind C1 of C1's goals, staff shadow C1 until it becomes unsafe, law enforcement is contacted, and all incidents are reported. Confidential interviews denied the allegation occurred however C1 has a history of frequently going AWOL from the facility. Based on confidential interviews, although the allegation that staff did not follow the facility emergency intervention plan resulting in C1 leaving the facility, may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this signed report was provided to the Program Director Deanna Mellos.

Investigation Findings:
13On 11/04/2022, at 11:30 a.m. Licensing Program Analyst (LPA) Marisol Lopez arrived at the facility unannounced and met with Program Director Deanna Mellos, of Center for Positive Changes 3 to discuss the investigative findings for the allegation noted above. On December 01, 2021 at 1:45 p.m., Licensing Program Analyst (LPA) Marisol Lopez conducted an unannounced complaint investigation at the above facility and met with Facility Director Anne Ford. LPA conducted a safety inspection, and no deficiencies were observed at that time. The investigation consisted of confidential interviews with one facility administrator, four facility staff, one client (C1), one social worker and review of incident reports. On 11/23/2021, the Department received an allegation that staff did not follow the facility emergency intervention plan resulting in C1 leaving the facility. Confidential interviews stated staff followed the emergency intervention plan however C AWOL'd frequently. Confidential interviews stated the facility is a hands free facility and is limited to how the staff can respond during an AWOL. (see continuation form LIC9099-C dated 11/04/2022) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Ann Valenzuela LICENSING EVALUATOR NAME: Marisol Lopez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, METROPOLITAN DR. # FACILITY NAME: CENTER FOR POSITIVE CHANGES 3FACILITY NUMBER: VISIT DATE: 11/04/2022

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

met_with: Program Director Deanna Mellos


summary: Facility Evaluation

raw_content:
Narrative:
On 06/09/2021 at 12: P.M., Licensing Program Analyst (LPA) Marisol Lopez and LPA Danielle Garcia conducted an unannounced required annual inspection of the facility and met with Program Director (PD) Anne Ford. LPA's and PD inspected the facility inside and out. Presently there are six children living in the home (C1, C2, C3, C4, C5, C6) (See Lic. Confidential Names dated 06/09/2021). The facility is a three-story residence with four bedrooms, five bathrooms, dining room, living room, kitchen, family room, laundry room, garage, and Games room. The facility has been operating with the capacity of six females from ages 13 years old to 17 years old and non-minor dependents. The bedrooms are arranged as follows: Master bedroom is on first floor and it contains two twin beds and an attached bathroom, all required linen present and mattresses were in good condition. Bedroom three is on the third floor contains two twin beds and an attached bathroom, all required linen present and mattresses were in good condition. Bedroom four is on the third floor and contains one twin bed and an attached bathroom shared with bedroom five, all required linen present and mattresses were in good condition. Bedroom five is on the third floor and an attached bathroom shared with bedroom four, all required linen present and mattresses were in good condition. Bedroom are arranged so that no more than two children share a room, and there is one child per bed. No room commonly used for other purposes is used as a bedroom. There is adequate drawer and closet space for children's belongings. The bathrooms were clean and in good repair. LPA tested the hot water temperature in clients' bathroom which read 118.0 degrees Fahrenheit, which is in range of 105- Fahrenheit. Licensee has obtained National Accreditation through CARF and the Accreditation is valid through August 2022. LPA's discussed the following with the Administrator: Incident reporting, including incidents related to Assembly Bill 388 law enforcement contacts as well as incidents involving emergency interventions. Personnel Files are maintained off-site and transported to LPA's within a reasonable time. All staff who work at the facility have Department of Justice and Child Abuse Clearance index check clearances. A review of client records was also completed on this date including the Medication Administration Record (See Confidential Name List- LIC 811 dated on June 09, 2021). Personnel files were reviewed to ensure they contained all required documentation. Children and staff records are organized. Staff's CPR and First Aid card were current. Child's records contain original needs and services plan signed by the child and their authorized rep. Child's records contain authorization for emergency medical care signed by each child's authorized rep. Facility personnel meet staff training requirements. Appropriate staff/client ratios were verified during this inspection. Based on observations made during the inspection, no deficiencies observed during today's visit. An exit interview was conducted and this report was reviewed with Program Director (PD) Anne Ford and a copy of this report was provided. Inside the facility there are battery operated smoke detectors in each bedroom, the office, family room, living room, game room and den and carbon monoxide detectors downstairs in the master bedroom and in the upstairs hallway. There are hard-wired smoke detectors in the kitchen and upstairs hallway. All smoke smoke detectors and carbon monoxide detectors worked properly. There are three fireplaces in the facility, which are properly screened. LPA's observed a sufficient supply of 7-day non-perishable food for six residents and a sufficient supply of 2-day perishable food in the kitchen. LPA's observed the kitchen to be clean, sanitary and in good repair. The dining room is located on the second floor and contains a table and six chairs and has built in cabinets that contain decorations and toys and games. The living room is located on the first floor and contains two couches, a desk and a table. The family room is located on the first floor and contains two couches, two chairs, a coffee table and a TV. The laundry room contains a washer and dryer and in it is a locked cabinet that contains cleansers. The attached 3 car garage is maintained locked and used as storage. The game room is located on the third floor. The staff office and staff bathroom are located on the second floor. The staff office contained office supplies, knives, medications, medication logs, the first aid kit, and clients' files. The medications are stored in a locked cabinet in the locked staff office. The first aid kit is stored in the staff office and contains all the required items. The licensee stated that there are no guns on the premises and sharp knives are kept locked in the staff office. There was an ample amount of recreational and leisure supplies such as books, games and television available for client use. Emergency exits were free from obstruction. The yard contains a outside area, with tables, chairs, a grill and swimming pool. The pool is surrounded an appropriate fence that is six-foot open metal fence with a self latching key locked gate at least 54 inches from the ground. Emergency exits were free from obstruction. The following required posted items were observed and accessible to children: Ombudsman and Foster Youth Bill of Rights, Grievance Procedures, Personal Rights, Visitation Policies, Neighbor complaint Policy, house rules and current menu.