summary: Complaint Investigation - Unsubstantiated - 1 deficiency - 1 allegation

raw_content:
Narrative:
The investigation revealed that the facility client went to school with multiple injuries as observed by school personnel. The facility administrator stated that the staff who supervised the client prior to the school observing the client's injuries did not document any injuries in the body check form which led to the staff's termination. In addition, the facility client's mother stated that she was notified by the former staff member of her son's behavior, but the former staff did not inform her of the injuries that was observed by the school. Other facility staff interviewed indicated that they were unaware as to how the client sustained the injuries. The facility client was non-verbal and had a history of exhibiting self-injurious behaviors. Based on the information gathered, the preponderance of evidence to prove the allegation was met, therefore the allegation is substantiated per California Code of Regulations Title 22 - refer to LIC9099-D for deficiencies. A copy of this report, Confidential Names Form, LIC 9099-D for deficiency and Appeal Rights were provided to the facility representative. The investigation revealed that the facility client went to school with multiple injuries as observed by school personnel. Multiple facility staff interviewed denied witnessing or subjecting clients to physical abuse. Investigator Douglas was unable to make contact with a former facility staff after multiple attempts. The facility client was non-verbal and had a history of exhibiting self-injurious behaviors. Based on the information gathered, the allegation is unsubstantiated as the preponderance of evidence to prove the allegation was not met although the allegation may have happened or is valid. A copy of this report, Confidential Names Form and Appeal Rights were provided to the facility representative.

Investigation Findings:
13On January 9, 2023 at 12: PM, Licensing Program Analyst (LPA) Joshua Rarela conducted a follow-up inspection to deliver the findings of a complaint investigation concerning the allegation above. The complaint was investigated by Community Care Licensing, Investigations Branch, Investigator Dennis Douglas. LPA Rarela discussed the findings with the facility representative named above. During the course of the investigation, Investigator Douglas interviewed facility personnel on 8/30/22, 11/29/22, 12/16/22, 12/22/22, and the facility client's biological mother on 9/6/22 (see Confidential Names Form dated January 9, 2023). Investigator Douglas also reviewed documents including police reports, facility complaints history, client records and facility incident reports. It was alleged that a facility client sustained multiple injuries due to neglect and lack of supervision, and that staff did not notify a facility client's responsible party of the client's injuries. (CONTINUED) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Joshua Rarela 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELLA VISTA AT TAYLORFACILITY NUMBER: VISIT DATE: 01/09/2023

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:

Deficiencies:
80078(a): 1
2
3
4
5
6
7

title:
Responsibility for providing care and supervision. The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement is not met as evidence by

description:
1
2
3
4
5
6
7


state: CA

facility_name: BELLA VISTA AT TAYLOR

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
On 02/10/2022, the Department received a complaint alleging allegations of lack of supervision and personal rights toward one client. It was alleged that client 1 has unexplained bruises, including that his cellular phone was taken away from him while speaking to a family member. The Facility Administrator (FA) including facility staff workers that provided a statement provided consistent statements and denied the allegations. FA reported that clients are not allowed to bring electronics to the table to avoid being distracted when eating. The FA and statements by facility staff stated that they would never take away a phone from a client while having or listening to a person on the phone. In confidential interviews, three clients were unable to provide clear and understandable verbal statements, and therefore no information was brought forth with respect to the allegations reported. The individual identified as other who disclosed some concerns for the focused client could not be contacted, therefore no statement was obtained. However, LA Co. Emergency Response Worker was able to obtain a statement and other corroborated the allegations reported. All professional collateral contacts, such as the county social worker (CSW), Regional Center Services Representative, including representatives from the client's school who are mandated reporters denied any concerns with the care and supervision by the facility staff workers. The school provided reports about the bruising, and it was not caused at the facility. Information obtained in the county reports reads that the City of Montebello Police responded to the facility and denied observing any abuse towards the clients and left the facility without further incident. The interviews obtained in the explanations about the lack of supervision and personal rights violations could not be corroborated. Therefore, the above allegations are determined unsubstantiated at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged abuse occurred. An exit interview was conducted and a copy of this report was provided to the above aforementioned for review and signature. No deficiencies were cited at this time.

Investigation Findings:
13On 03/29/2023 at 01: PM Licensing Program Analyst (LPA) Joseph Vargas conducted a follow-up complaint inspection to the above facility and met with Ms. Henry. The purpose of the inspection was to deliver the finding for the above complaint allegations. During the course of the investigation, LPA interviewed Facility Administrator (FA), two facility staff workers, two school staff personnel, three clients on 02/15/2023, county social worker (CSW), regional service center worker (RSC) on 2/17/2023, attempted contact with individual identified as other, last attempt was on 03/15/2023, two facility staff workers on 03/28/2023 (refer to Confidential Names Form LIC 811 dated 03/29/2023). During the inspection LPA requested for review and obtained copy of staff and client facility roster reports, special incident reports, clients' Needs and Service Plan, and placement history, including a review of the county reports associated with this complaint. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jean Herring LICENSING EVALUATOR NAME: Joseph Vargas 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 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION LA & TRI-COASTAL CR, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELLA VISTA AT TAYLORFACILITY NUMBER: VISIT DATE: 03/29/2023

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

report_type: Complaint Investigation

met_with: Ms. Henry, Administrator

complaint_status: unsubstantiated


raw_content:
Narrative:
Client was able to participate in a community walk the evening after the incident. Due to this, staff did not inform the Administrator of the incident but noted what occurred on the daily log. The Administrator provided a refresher training on incident reporting requirements to facility staff on 4/17/24. Client was unable to explain how the bruises were sustained when interviewed by the LPA. Records show that client was not cooperative during an interview by another investigating agency but appeared happy and comfortable at placement. Although there were faint bruises observed, client did not appear to be in pain. There were no witnesses and no records found to corroborate the allegation. Based on information obtained, the allegation is closed as unsubstantiated because the preponderance of standard of evidence was not met. A copy of this report and the Confidential Names Form dated 6/18/24 were provided to the facility representative. Appeal rights forms were also provided and explained.

Investigation Findings:
13On June 18, 2024 at 11:50am, Licensing Program Analyst (LPA) Irene Yamamoto conducted a complaint inspection at the facility to deliver the finding of the allegation. LPA met with the facility representative named above. The allegation was investigated by the LPA. Interviews were conducted with the client on 4/12/24, facility staff on 4/17/24 and 5/1/24 and other related parties between 4/12/24 and 5/1/24. Client records and other complaint-related documents were reviewed on 4/12/24 and 5/24/24. During the course of the investigation, it was discovered that client was observed with what appeared to be discolored bruises on the buttocks, but client was unable to explain how the bruises were sustained. Interviews revealed that the client stumbled and fell, hitting the steps of a slide, during an outing at a local playground. Client did not complain of any pain or discomfort and there were no injuries observed on the client by staff when the incident occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Irene Yamamoto 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 32-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION MONTEREY PARK CRP RO, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELLA VISTA AT TAYLORFACILITY NUMBER: VISIT DATE: 06/18/2024

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

met_with: DeVona Woods, Facility Manager/DSP II


summary: Complaint Investigation - Substantiated

raw_content:
Narrative:
On 12/09/2024, the Department received a complaint alleging that Staff spoke inappropriately to youth. The focused staff (S1), who was identified in the report, denied the allegation, and stated that the youth was not called an inappropriate name and there was not an inappropriate comment made to the youth. S1 stated that the youth had a behavior episode when the youth was told he has passed the number of calls that the youth was allowed to make. The youth began arguing with S1 and S1 stated that during the argument the youth called another youth in the home a retard. S1 explained to the youth that this word is not to be used and he should use the term intellectual challenged. S1 stated that the youth was told that all the youth in the facility are all the same and fall within the same spectrum and that the youth was diagnosed as a retard. Other staff in the facility stated that they never heard S1 call the youth a retard and S1 only redirects the youth. The focus youth (C1) stated that S1 called him a retard on several occasions and that nobody was around. C1 stated that S1 calls him names to get back at him and S1 called him a retard when he called the other youth in the facility a retard. C1 stated that he did not know if S1 was explaining to him not to call the other youth a retard or if S1 was calling him a retard to bother him. Based on the information from staff, youth, collateral contacts and documents reviewed the allegation is found to be substantiated. A substantiated finding means that the preponderance of evidence standard has been met and the allegation is found to be true. Exit interview completed. The following deficiencies cited and a copy of this report and appeal rights were left with facility representative mention above.

Investigation Findings:
13On March 11, 2025, Licensing Program Analyst (LPA) Heriberto Perez conducted a follow-up complaint inspection to the above facility and met with Shakisha Henry, Administrator. The purpose of the inspection was to deliver the revised finding for the above complaint allegations. During the course of the investigation, LPA interviewed one staff and one youth in person in the facility and conducted telephone interview with County Social Worker (CSW2) on 12/12/24, LPA conducted telephone interivew with County Social Worker (CSW) on 12/19/24, LPA conducted telephone interviews with three staff and interviewed one minor in person on 02/25/25 (see Confidential Names Form LIC 811 dated March 11, 2025). LPA also reviewed documents including but not limited to Client's Need and Service Plans, Special Incident Reports (SIR), client's notes, law enforcement report and other documents. It was alleged Staff spoke inappropriately to youth. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Gustavo Garcia LICENSING EVALUATOR NAME: Heriberto Perez 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 32-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, CORPORATE CNTR DR. #200A MONTEREY PARK, CA FACILITY NAME: BELLA VISTA AT TAYLORFACILITY NUMBER: VISIT DATE: 03/11/2025

met_with: Shakisha Henry, Administrator

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
On 05/20/2022 at 8: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced Annual Licensing Inspection at the facility. LPA met with Administrator, Shakisha Howard. The facility currently has a Group Home (GH) license. The facility is licensed to serve four (4) regional center clients with mild to severe developmental disabilities ages 7-17 years old. There are currently four (4) clients in placement. The LPAs requested the following: Personnel Report LIC500, Client Roster, Board of Meeting Minutes, Clients and Staff Files. The facility is a single-story home with four (4) bedrooms, living room, dining room, kitchen, backyard and three (3) restrooms. There are no firearms or ammunition in the facility. There are no bodies of water in the facility premises. At 8: AM, LPA conducted a walkthrough of the entire facility. Physical Plant The license, facility sketch, personal rights, emergency disaster form, complaints poster, emergency phone numbers and food menu are posted in a prominent, publicly accessible location in the facility. Disinfectants and cleaning solutions are kept inaccessible and locked in a cabinet located in the garage. Sharps/knives are inaccessible and stored in a locked cabinet in the kitchen. Facility has non-perishable food for at least one week and perishable food for at least two days. Medications are centrally stored in a locked cabinet in the hallway. Smoke and carbon monoxide detectors were tested and in proper working order. Fire extinguisher was fully charged. First Aid Kits were checked and found to be complete. Room temperatures are maintained at 76 degrees F. The hot water temperature was tested and measured at 110 degrees F. All sinks, showers and toilets are in working order. No more than 2 children share a bedroom. All beds are in good repair; equipped with good springs, clean mattresses and pillows. Adequate supply of beddings and linens were observed. Facility provides age-appropriate clothing items and hygiene products. Overall, facility is clean, safe, sanitary and in good repair. Operations Facility maintains a register of clients and the register is available upon request. The board of directors regularly conduct meetings to review and discuss the facility's operation. The facility administrator is the responsible and capable staff for communicating with emergency personnel in the facility. The facility has developed, maintained and implemented written complaint procedures. Disaster Preparedness Plan Facility maintains a current, written disaster and mass casualty plan of action. Facility conducts disaster drill at least monthly for each shift. The drills are documented, and the documentation is maintained in the facility for at least a year. Facility maintains an emergency and disaster plan, register of clients, Needs and Services Plan for each client, medication records, and contact information for each client's responsible party and physician. Emergency Intervention Plan LPA reviewed the facility's emergency intervention plan. Facility does not use manual restraints. Facility has an emergency intervention training curriculum. All staff members are trained on the facility's emergency intervention procedures. Client Records LPA reviewed four (4) client records. All client records are available to the licensing agency to inspect, audit and copy upon demand. Client records contain required information including, but not limited to, consent forms, court orders, needs and services plan, removal/discipline/complaint procedures; medical assessment; safeguards for cash resources; education records; personal rights forms; and medication administration records. During records review, LPA observed that all four (4) clients' account of personal property/valuable were missing and/or not updated. It was also observed that psychotropic medications are not logged separately for each psychotropic medication. One (1) Type B deficiency citation and one (1) Advisory Note Technical Violation were issued during today's inspection, see LIC809D and LIC9102TV. An Annual Continuation is required at a different time. The administrator was provided information on where to locate the Provider Information Notices (PINs), guidance to the new CARE Tools inspection process and Guardian. An exit interview was conducted, and a signed copy of this report, LIC809D, LIC9102TV, LIC811 and appeal rights were provided to the facility administrator.

report_type: Facility Evaluation

visit_type: Annual

met_with: Shakisha Howard


summary: Facility Evaluation

raw_content:
Narrative:
On 05/24/2022 at 8: AM, Licensing Program Analyst (LPA) Pamela Silva conducted an unannounced Annual Continuation inspection at the facility. LPA met with Administrator, Shakisha Howard. This inspection is a continuation of the annual inspection conducted on 05/20/2022. At 9: AM, LPA Silva reviewed two (2) staff records. Staff Records All staff have been subjected to criminal records review and have been fingerprinted and cleared with DOJ, FBI and CACI. The administrator meets the required qualifications and/or experience. Documentation of the required education and experience requirements are maintained in the personnel file. LPA verified 20 hours of annual training for direct care staff. Clients with Special Health Care Needs There are currently no clients in care with special health care needs. LPA interviewed two (2) staff members. There are no citations assessed during this inspection. An exit interview was conducted. A signed copy of this report and LIC811 were provided to the facility administrator.

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Carrie Palmer conducted an unannounced visit to the above facility on 5/15/2023 at 9: AM for the purpose of conducting a required annual inspection. LPA met with Administrator, Shakesha Howard (Henry). LPA reviewed a copy of an updated Personnel Report (LIC 500), The Register of Facility Clients/Residents listing 1 child and the Emergency Disaster Plan for Children's Residential Facilities. LPA along with the facility staff conducted a tour of the facility inside and outside of the home. There is 1 client currently residing in the home with special needs. The following was observed during the inspection: Physical Plant/Personal Accommodations (Buildings and Grounds) - The facility is a one story home. LPA observed the following on the first floor: Four (4) bedrooms, 1 kitchen which includes an area with a table, 1 office, 1 storage area for medications, 3 bathrooms, 1 living room the backyard, and a garage. The Facility License is posted in plain view in the living room. LPA reviewed the Emergency Disaster Plan, Client Grievance Procedures and Rights of Individuals with Developmental Disabilities, which was posted in plain view. The following sleeping arrangements were noted: Bedroom # 1 sleeps 1 client and has 1 beds, 1 dresser and closet Bedroom # 2 sleeps 1 client and has 1bed, 1 dresser and closet Bedroom # 3 sleeps 1 client and has1 bed, 1 dresser and closet. Bedroom # 4 sleeps 1 client and has 1 bed, 1 dresser and a closet. The room has its own bathroom (Master) . All beds are clean. Three of the four beds are in good repair. Food Service - The facility maintains adequate perishable and non-perishable food supplies; the menu plans for the week and weekly program schedule of activities are posted. The kitchen utensils, glasses and dishes were found to be in good condition. There is a back up refrigerator in the garage used for overflow of food items. The hot water temperature was tested and found to be in the mandated range. All exits were free of hazards and all doors opened freely. There is adequate space for indoor and outdoor activity. Exit signs were posted throughout the facility. Sharp knives, medications, and cleaning supplies are kept locked in areas inaccessible to clients. Interviews (Staff): LPA interviewed 2 staff (Administrator), and Direct Care Staff (DCS) Interviews (Clients): LPA didn't interview clients as the client is non-verbal. File Review: No file reviews were conducted during this inspection. An exit interview was conducted. A copy of the LIC 809, 809C, 809Ds, Appeals Rights, 9102, and LIC 811 were provided to the facility representative. At the time of this inspection there is Type A, Type B, and Technical Assistance.

met_with: Shakesha Howard (Henry) - Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Carrie Palmer conducted an unannounced visit to the above facility on 5/08/2024 at 12: PM for the purpose of conducting a required annual inspection. LPA met with Administrator, Shakesha Howard (Henry). LPA reviewed a copy of an updated Personnel Report (LIC 500), The Register of Facility Clients/Residents listing 1 child in care. LPA along with the facility staff conducted a tour of the facility. There is 1 client currently residing in the home with special needs. The following was observed during the inspection: Physical Plant/Personal Accommodations (Buildings and Grounds) - The facility is a one story home. LPA observed the following on the first floor: Four (4) bedrooms, 1 kitchen which includes an area with a table, 1 office, 1 storage area for medications, 3 bathrooms, 1 living room the backyard, and a garage. The Facility License is posted in plain view in the living room. The following sleeping arrangements were noted: Bedroom # 1 sleeps 1 client and has 1 beds, 1 dresser and closet Bedroom # 2 sleeps 1 client and has 1bed, 1 dresser and closet Bedroom # 3 sleeps 1 client and has1 bed, 1 dresser and closet. Bedroom # 4 sleeps 1 client and has 1 bed, 1 dresser and a closet. The room has its own bathroom (Master) . All beds are clean. An exit interview was conducted. A copy of the LIC 809 and 811 was provided to the facility representative. At the time of this inspection there were no deficiencies cited per Title 22 regulations.

met_with: Shakesha Howard (Henry), Administrator


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
Licensing Program Analyst (LPA) Carrie Palmer conducted an unannounced visit to the above facility on 05/21/2024 at 11: AM for the purpose of conducting a Required Annual Inspection Continuation. LPA met with the Administrator and discussed the purpose of the visit. During the inspection, LPA Palmer completed the following domains: Operational Requirements, Emergency Intervention Plan, Staffing, Staff Records, and Client Records and interviews with staff and clients. The Special Needs Domain was also completed. LPA Palmer conducted 1 of 1 client file review and 3 of 8 staff file reviews. There is 1 client in care at this time. LPA Palmer requested to see the following: staffing schedule, administrator's resume, administrator certificate, current physicians' orders, staff job descriptions, training certificates, staff applications for employment, proof of staff training, cash resources and medication. Operations: The facility has an indoor and outdoor activity plan, which is hung in the dinning area in plain view. LPA Palmer was able to see board meeting minutes, written compliant procedures posted to include a drop box for staff and clients to communicate their concerns. LPA Palmer also discussed the importance of the awareness of the Child Abuse Hotline. Disaster Preparedness and Emergency Intervention: The facility was able to provide their emergency drill binder to include drills for fire, earthquake, violent and threatening situations, utility failure and bomb threat. The staff training binder was also provided to LPA Palmer which includes: SIRs and Abuse, Oral Hygiene, Medication Training, Data HCBS New Rule and Body Checks. During an interview with staff it was determined that staff needs more training on the understanding of the needs and services plan as well as the emergencies intervention plan. Client Records: The facility was able to present the P and I Binder (Personal and Incidentals), which includes the cash resources form (LIC 405), cash and receipts - all in good standing. LPA Palmer was also able to review the MAR (Medication Administration Record), which includes: the name of the medications, the side effects, the initials for staff after , the dosage, birthdate and area for allergies to be listed. The staff was able to provide medical/dental exams and immunizations. Psychotropic medications are supported by consent forms. Staff Records: During the review of 3 staff records, it was determined that staff received background checks prior to working at the facility. It was also observed that staff receives ongoing training that consists of, but not limited to the following: CPI Training, Title 22, Management and Aggression, Non Punishment Procedures, Replacement Behaviors, Communication, Chocking, Break Schedules. Certificates of completion were provided for the following: Nutrition for Healthy Living, Emergency Disaster Preparedness, and Regional Center Training. Job Descriptions were also observed within the staffs files and the administrators certificate is not up to date, but the administrator was able to show that she is on the ACS list for her certificate to be issued. One of the three staff files did not include the staffs job description. The facility corrected the non compliance during the visit. Clients with Special Health Care Needs: During observation and interview, it was determined that the special needs individualized health care plan/needs and services plan was not being updated every 6 months, but was being updated annually. Clients have assessment plans and placement document from DFCS; as the documentation shows custody and disability info. Clients have assessment plans and placement document from DFCS; as the documentation shows custody and disability info. The following will be issued during todays visit: TV and Citation. And exit interview was conducted and an 809, 811, TV, Type B, and Appeals Rights has been provided to the facility representative. D

Deficiencies:
81022(j): Plan of Operations, which states:

title: Title 22. Div 6 Article 3 Application Procedues

description: Plan of Operations, which states:


summary: Facility Evaluation

raw_content:
Narrative:
On 03/12/2025 at 10: Licensing Program Analyst (LPA) Olena Maico arrived at the facility for the case management to review the staffing requirement to meet Title 22 . LPA met with Shakisha Henry, Administrator. LPA presented the Administrator with the Program Statement Regional Office has on file and the Administrator presented the Program Statement for the facility that differs from the one Regional Office has on file. LPA inquired when the Program Statement has been updated and if it was sent to Regional Office for review. Administrator was not aware when exactly the change occurred and if the Program Statement has been approved. LPA requested that the Administrator and the Licensee send the new Program Statement for the approval to the Regional Office, since the Group Home cannot operate with the Program Statement that has not been approved by the Regional Office. LPA also noted that if the Licensee did send the statement for approval, LPA would need the letter of approva sent to the licensee by the Regional Office. Administrator stated she will meet with the licensee to discuss the issue and they will send the amended Program Statement for approval. During the brief review, LPA noticed the new Program Statement was missing Facility Manager and Psychiatric Technician Jobs descriptions. LPA noted those have to be added to the Program Statement. Administrator also will send the new LIC 500 with the Facility Manager schedules to comply with Title 22. LPA is requesting the amended Program statement and LIC 500 to be sent by March 26,2025. LPA also advised the Administrator to ensure the personnel requirements are met for the staff for the facility manager. LPA notified the Administrator LPA will be back with another case management to review the LIC 500 and staff qualifications once the Program Statement is reviewed and approved or will reach out if any changes are needed. LPA also advised that the in office meeting might be scheduled to review the Program Statement or if any further assistance is needed and Administrator and Licensee have any questions. No deficiencies cited at this time. The copy of this report was e-mailed and explained to the Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On 06/06/2025 at AM Licensing Program Analyst (LPA) Olena Maico conducted an unannounced visit to the above facility for the purpose of conducting a required annual inspection. LPA met with Administrator, Shakisha Henry. LPA requested via e-mail prior to the inspection and reviewed a copy of an updated Personnel Report (LIC 500), The Register of Facility Clients LIC 9020, LIC 308, LIC 309, LIC 610C. During the visit LPA requested and reviewed Board Meeting Minutes, Emergency Disaster Drill log, restraint log. LPA along with the facility staff conducted a tour of the facility. There is 1 client with special needs currently residing in the home. The following was observed during the inspection: Physical Plant The facility is a one story home. LPA observed the following on the first floor: Four (4) bedrooms, kitchen which includes an area with a table and 3 chairs, 1 office, 1 storage area for medications, 3 bathrooms, 1 living room with the TV and couch for clients to use, the backyard with tables and chairs, and a garage. The Facility License is posted in plain view in the living room. The kitchen has counter with four stools, working fridge, stove, microwave, sink. LPA observed plenty of fruits on the counter as well as the shelves with the various activities for the clients (games, play-doh, sensory activities games etc). LPA observed CARF certification, Emergency Disaster Plan, Persons with Disabilities Rights poster, weekly and daily activities list posted in the kitchen. Temperature inside the facility was at 72 degrees F. LPA observed plenty of perishable and non-perishable foods. LPA also observed the menu posted on the wall in the kitchen. The following bedroom arrangements were noted: all bedroom have one full bed, storage dresser, closet and plenty of room for the clients to use. LPA observed 3 bathrooms at the facility with the working sink, shower and toilet. The facility is clean and sanitary and in good repair. LPA observed screens in good condition on all the windows. LPA observed trash cans without lids in the bathrooms and issued technical violation to the facility. Administrator will get the trash cans with lids for each bathroom. Kitchen trash can had cover on it. Operations The facility has an indoor and outdoor activity plan, which is hung in the dinning area in plain view. LPA Maico was able to review board meeting minutes, grievance procedures. Disaster Preparedness and Emergency Intervention The facility has the Emergency Disaster Plan posted at the facility with the phone numbers and e-mails. The facility was able to provide their emergency drill binder to include drills for fire, earthquake, violent and threatening situations, utility failure and bomb threat. LPA reviewed manual restraints log and the EIP certificates for the staff. Clients files LPA reviewed one (1) client file. LPA observed admission agreement, information for the medical and dental providers, medical and dental records, medication administration logs, copies of the IPPs, vaccination and TB test records. Staff files LPA reviewed 5 (five) staff files. LPA reviewed the criminal record clearances, training for the staff, child abuse reporting, emergency intervention training. Training includes but not limited to child abuse reporting, cultural competency, autism spectrum disorder, Personal Rights, Health and Safety Practices. LPA attempted to interview one client and LPA interviewed one staff. LPA issued one Technical Assistance and two Technical Violations to the facility. No deficiencies issued at the time of inspection. The copy of this report and LIC 811 was given to the facility Administrator.


facility_name: BELLA VISTA EVERGREEN HOUSE

summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Investigation Findings:
13Licensing Program Analyst Connie Jones-Steward met with Maria Luna at Bella Vista Maple because no one was available at the Evergreen location. The purpose was to finalize this complaint investigation. LPA arrived at the Maple St. location at 12: PM after having been to the Evergreen location at 12: PM. On July 19, 2021, Licensing Program Analyst Connie Jones-Steward received an emailed copy of a clearance letter from a company named Mold Inspection & Testing. The letter indicated that professional mold remediation was not required. LPA Jones-Steward contacted the technician who issued the letter for clarification. The technician informed LPA Jones-Steward that mold was found at the home. However the level of mold was not enough to presentt an immediate health hazard. The technician stated that he had verbally advised the administrator to enlist a prfessional HVAC cleaner to remove the mold that did exist. Based on consultation with the technician who inspected the home, the allegation that mold was found in the home was substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: BELLA VISTA EVERGREEN HOUSEFACILITY NUMBER: 198209656

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

met_with: Maria Luna


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13Licensing Program Analyst Connie Jones-Steward investigated the above allegation. LPA interviewed the administrator, facility manager, direct care staff and the police officer who witnessed the reported allegations. LPA also reviewed the client's most recent individualized personal plan (IPP) and the schedule for the date of the incident. LPA found that there was only one staff person on duty during the time of the AWOL. However based on the client's IPP, she had AWOLED several times in a 6 month period and was prone to agressive and assaultive behavior. Her AWOL frequency and violent behavior were indicative of a need for increased supervision. Based on the available information, the above allegations are resolved as substantiated. Substantiated means that there is a preponderance of evidence that the allegation true. Facility was cited under 80078(a) Responsibility To Provide Care and Supervision SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: BELLA VISTA EVERGREEN HOUSEFACILITY NUMBER: 198209656

met_with: Lavetha Oliver, Administrator for Zook


summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13Licensing Program Analyst Connie Jones-Steward interviewed the above allegations. LPA interviewed C1, C1's mother, the facility manager, and two direct care staff persons including the alleged assailant. C1 was not capable of providing a coherent account of what had happened to lead to the allegations. Other parties either disagreed about the incident or claimed to not know anything about it. Staff 1 and the facility manager deny that the allegations are true. They both deny that C1 is not allowed to use the restroom or that Staff 1 has done anything to frighten C1. Based on the available interviews and information, these allegations are resolved as unsubstantiated. Unsubstantiated means that although an allegation may have happened, there is not a preponderence of evidence to prove that it did. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

met_with: La' Donne Wallace


summary: Facility Evaluation

raw_content:
Narrative:
On February 15, 2022 at 9:30am Licensing Program Analysts (LPA), Olivia Rosas arrived at the above facility unannounced for the purpose of conducting a SB Psychotropic Medication Case Management- Medication Inspection Visit. LPA Rosas met with Facility Manager (Staff#1) and Administrator (Staff#2). LPA Rosas was not able to reviewed or interviewed client files due to no clients in placement. LPA Rosas reviewed two (2) staff files and conducted two (2) staff interviews. The facility is currently not operational and has no clients are residing in the above facility. This is a facility located in a residential area and equipped with four (4) bedrooms, one (1) staff office, two (2) bathrooms, living room, dining room, kitchen, laundry room, and medication room. There are no bodies of water on the premises. Common areas area clean and in good repair. Rooms are fully furnished with one bed, and closet space. Outdoor space is free of obstructions. LPA Rosas observed the facility to be clean, safe, sanitary and in good repair. The facility currently has no staff employed or clients in placement. On September 28, 2021 the facility reported to the Department they are temporary not going to operate due to not having clients in placement. LPA Rosas also observed medication to stored in the medication room, double locked and inaccessible to clients and unauthorized staff members. There were no deficiencies cited at this time. Exit interview was conducted, and a copy of this report was left at the facility.

met_with: Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward conducted the Required 2 year Inspection on this date. The following was observed. This is a 4 bedroom, 2 bathroom home located in a residential section of the City of Burbank, CA. There are currently no clients in placement. All bedrooms have one single bed with good mattresses and the required linens. There is adequate storage space available in each bedroom. There are working smoke and carbon monoxide detectors in each bedroom. There are no security bars on windows. All windows are functional. There are two fully charged fire extinguishers in the home. There is a locked storage area for medications. There is a complete supply of first aid items. The kitchen area is clean with refrigerator and stove in good working condition. There is an automatic dishwasher. There is at least one week supply of canned and dried food on hand. Backyard is free of hazards. Both bathrooms are clean with equipment in good working order. Hot water temperature is within the safe range. License, Notice of Personal Rights and Floor Plan are posted as required. The CARF certification is current through August 2024. LPA requested that the licensee submit a current LIC 500 to the department. A subsequent visit will be scheduled to review employee records. There were no citations issued.

met_with: Stephen Smith, Interim Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward conducted the annual random Inspection on this date. The following was observed. This is a 4 bedroom, 2 bathroom home located in a residential section of the City of Burbank, CA. There is currently one client in placement All bedrooms have one single bed with good mattresses and the required linens. There is adequate storage space available in each bedroom. There are working smoke and carbon monoxide detectors in the bedrooms and hallways. There are no security bars on windows. All windows are functional. There are two fully charged fire extinguishers in the home. There is a locked storage area for medications. There is a complete supply of first aid items. The kitchen area is clean with refrigerator and stove in good working condition. There is an automatic dishwasher. There is food on hand to meet Title 22 requirements. Backyard is free of hazards. Both bathrooms are clean with equipment in good working order. Hot water temperature is within the safe range. License, Notice of Personal Rights and Floor Plan are posted as required. LPA requested that the licensee submit a current LIC 500 to the department. A subsequent visit will be scheduled to review employee records and conduct employee interviews. Client records were reviewed. The only client in care is non-verbal..

met_with: Lavatha Oliver, Interim Administrator


facility_name: BELLA VISTA MAPLE HOUSE

raw_content:
Investigation Findings:
13Licensing Program Analyst Connie Jones-Steward investigated the above allegations. LPA interviewed group home staff and regional center staff. LPA reviewed the admissions agreement, the IEP and the investigations report by regional center staff. C1 aged out of the facility and was non-verbal. The IEP did not mention that C1 had any issues that would have supported the details of the original allegation. Per staff, this condition was sudden onset and triggered by the client having to leave the facility due to his age. There was no incident filed with the Department concerning this change in behavior. The investigation by this LPA failed to reveal any ongoing behaviors that would support the allegation that the staff failed to maintain the bedroom of C1 in a clean condition. Therefore the allegation is resolved as "unsubstantiated". Unsubstantiated means that an allegation lacks a preponderance of the evidence to prove that the violation occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Stephen Smith


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward met with administrator Stephen Smith to conduct the Required 2 year inspection. The following was observed: This is a single story home located in the city of Burbank, CA. There are four bedrooms, two bathrooms, living room, den, staff office, kitchen, and dining area. The home is licensed to provide care and supervision to four (4) developmentally disabled children ages 6-17, ambulatory only. There are currently four children in placement. LPA found the yard area to be free of hazard. The swimming pool has been removed. There are working smoke detectors and carbon monoxide detectors in each bedroom and in each hallway. There are no security bars on windows. There are two fully charged fire extinguishers in the home. CARF certification is current. The last disaster drill was documented 12/20/22. Bathroom and kitchen areas are clean with equipment in working order. All sharp knives, household cleaners and medications are safely stored in locked areas. The food supply exceeds Title 22 requirements for two days of fresh food and 1 week of non-perishable foods. All food groups are represented. All bedrooms have one twin bed each with mattresses and the required linens. There is adequate drawer and closet space for each client. The following is posted as required: License, menu, notice of personal rights, house rules, employee schedules and disaster plan. Administrator was advised to update employee schedule and disaster & mass casualty plan. LPA will return to review the staff and client records. There were no deficiencies cited as a result of this inspection.

met_with: Stephen Smith, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward met with administrator Stephen Smith to complete the annual inspection. 4 employee files were reviewed. LPA advised administrator that there were required documents missing from the employee files and an advisory note was issued. One employee was interviewed. All clients are non-verbal and therefore were not interviewed. There were no deficiencies issued.


summary: Facility Evaluation

raw_content:
Narrative:
LPA Connie Jones-Steward visited the facility on September 15, 2023 to verify that employee #1 was removed from the facility due to the exclusion order. LPA viewed current work schedule and LIC 500. Neither had the employee #1 listed. LPA Jones-Steward also viewed the notice of termination and exit interview served to employee #1 by Administrator Stephen Smith. Copies of documents were obtained for Department file. The administrator has demonstrated proof that Employee #1 was terminated from employment with Bella Vista Maple on August 31, 2023


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward met with administrator Stephen Smith to conduct the Annual/Random inspection. The following was observed: This is a single story home located in the city of Burbank, CA. There are four bedrooms, two bathrooms, living room, den, staff office, kitchen, and dining area. The home is licensed to provide care and supervision to four (4) developmentally disabled children ages 6-17, ambulatory only. There are currently four children in placement. LPA found the yard area to be free of hazard. There are working smoke detectors and carbon monoxide detectors in the hallway. There are no security bars on windows and windows are fully functional. There are two fully charged fire extinguishers in the home. CARF certification is current. The last disaster drill was documented 04/01/2024. Bathroom and kitchen areas are clean with equipment in working order. All sharp knives, household cleaners and medications are safely stored in locked areas. The food supply exceeds Title 22 requirements for two days of fresh food and 1 week of non-perishable foods. All bedrooms have one twin bed each with mattresses and the required linens. There is adequate drawer and closet space for each client. The following is posted and current as required: License, menu, notice of personal rights, house rules, employee schedules and disaster plan. LPA Jones-Steward reviewed client records and medications. Staff records and interviews will conducted at a future date.


facility_name: BELLA VISTA WYOMING HOUSE

summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13Licensing Program Analyst Connie Jones-Steward met with Ms. Henry to resolve the allegations. This allegation was previously discussed with the previous administrator Teandra Pitts. During the discussion with Ms. Pitts it was determined tha Community Care licensing was not receiving incident reports. The incident reports were batch submitted to CCL on 05/28/21 after LPA informed Ms. Pitts of Title 22 reporting requirements. Based on the above information, the allegation was substaintiated. A substantiated finding means that the "preponderance of the evidence" standard has been met. The facility was cited under Title Regulation Reporting Requirements. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: BELLA VISTA WYOMING HOUSEFACILITY NUMBER: 198209658


raw_content:
Investigation Findings:
13Licensing Program Analyst Connie Jones-Steward met with administrator Shakisha Henry to resolve the allegations, The allegations were previously discuseed with former administrator Teandra Pitts. LPA reviewed several Monthly Progress reports for C1. The reports show a pattern of aggression towards self and others that does leave bruises. However review of work schedules and interviews with various parties indicate that staff is scheduled to be present in the numbers that would allow for 1:1 supervison. The monthly progress reports also indicate that efforts are being made to help C1 improve in his weak areas. Based on staff interviews, witness interviews and review of client progress reports, the above allegations of Lack of Supervision or resolved as unsubstantiated. An unsubstantiated finding means that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

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


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13Licensing Program Analyst Connie Jones-Steward met with administrator Shakisha Henry to resolve the above allegations. The allegations were initially discussed with former administrator Teandra Potts. During the course of the investigation it was dtermined that when C1 would not eat certain foods, he was given snacks that he would eat as an alternative because the staff did not want to cook two separate meals. LPA discussed with Ms. Henry that since food is a major source of anxiety with C1 that efforts should be made to ensure that all meals include foods that appeal to him as well as the other clients. Based on interviews and file reviews, this allegation was resolved as substantiated. A substantiated finding means that the "preponderance of the evidence" standard has been met. The facility was cited under Title 22 80076(a)(2) SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: BELLA VISTA WYOMING HOUSEFACILITY NUMBER: 198209658

met_with: Shakisha Henry


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13Licensing Program Analyst Connie Jones-Steward met with administrator Shakisha Henry to resolve the above allegations. The allegations were initially discussed with former administrator Teandra Potts. Per Ms Henry and Ms. Potts there were miscommunications that led to C1 being sent to school without a sufficient supply of diapers or clothing changes. Ms. Henry also admitted that a former employee had ruined the clothing of C1 by using too much bleach in the wash. On the date of inspection, LPA reviewed the clothing of C1 and found that the ruined clothing had been replaced by clothing in good condition. LPA ws not able to reach school personnel, but both the mother and regional center coordinator for C1 agreed that he was no longer being sent to school eith insufficient clothing. Based on the investigation, interviews and review of C1's file the above allegations were found to be substantiated. A substantiated finding means that the "preponderance of the evidence" standard has been met. The facility was cited under Title Section 80078(a). SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: BELLA VISTA WYOMING HOUSEFACILITY NUMBER: 198209658


raw_content:
Investigation Findings:
13Licensing Program Analyst Connie Jones-Steward met with administrator Shakisha Henry to resolve the above allegations. The allegations were initially discussed with former administrator Teandra Potts. During the course of investigating this allegation, LPA was uable to determine if the mother's visits with C1 were being restricted due to any form of retaliation or to the COVID restrictions which were in place for all parents. Therefore this allegation was resolved as unsubtantiated. An unsubstantiated finding means that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

met_with: Shakisha Henry, administrator


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13Licensing Program Analyst Connie Jones-Steward investigated the above allegation. LPA reviewed client records and interviewed staff, behavioral consultants, regional center coordinators and parents, LPA also made personal observations of the suprvision being provided to clients on two separate visits. Based on the records reviews, interviews and personal observations, it was determined that Bella Vista Wyoming has not been providing the supervision that is necessitated by the clients needs and required by the regional center. LPA has personally observed the facility to not adhere to the ratios required by regional center. LPA has also been advised by several witnesses that the facility is frequently in violation of the said ratios, Therefore the allegation is substantiated A substantiated finding means that there is a preponderance of evidence that an allegation did occur. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: BELLA VISTA WYOMING HOUSEFACILITY NUMBER: 198209658


raw_content:
Investigation Findings:
13Licensing Program Analyst Connie Jones-Steward investigated the above allegation. LPA reviewed client records and interviewed staff, behavioral consultants, regional center coordinators and parents, LPA also made personal observations of the supervision being provided to clients during two separate visits. Based on the records reviews, interviews and personal observations, it was determined that Bella Vista Wyoming has not been providing the supervision that is necessitated by the clients needs and required by the regional center. LPA has personally observed the facility to not adhere to the ratios required by regional center. LPA has also been advised by several witnesses that the facility is frequently in violation of the said ratios, Therefore the allegation is substantiated A substantiated finding means that there is a preponderance of evidence that an allegation did occur. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B This is an official report of an unannounced visit/investigation of a complaint received in our office on 07/20/2022 and conducted by Evaluator Connie Jones-Steward COMPLAINT CONTROL NUMBER: 34-CR- FACILITY NAME:BELLA VISTA WYOMING HOUSEFACILITY NUMBER: ADMINISTRATOR:MEJIA, CARLOSFACILITY TYPE: ADDRESS: WYOMING AVENUETELEPHONE: (626) 794- CITY:BURBANKSTATE: CAZIP CODE: CAPACITY:3CENSUS: 2DATE: 02/15/ UNANNOUNCEDTIME BEGAN: 11: AM MET WITH:TIME COMPLETED:12: PM -Client sustained injuries Health Related Services -Staff did not provide first aid -Staff smoking cigarettes on premises INVESTIGATION FINDINGS: 13Licensing Program Analyst Connie Jones-Steward investigated the above allegations. LPA interviewed facility staff, regional center staff, parents and behavioral consultants. Facility records indicate that the bruise on the hand of C1 was noted in the daily log and that minor first aid had been applied. However, the facility staff stated that the injury happened at the client's school. Meanwhile the complainant is not certain where the injury occured. Due to conflictiong stories, LPA was not able to determine where the injury occured or if first aid was actually applied. Likewise, LPA was unable to obtain congruent assounts of whether or not staff was smoking on the premises. The staff questioned stated that he does smoke on his own time but not on the premises. LPA found no evidence in the form of ash leavings, discarded cigarette butts or tobacco odor in the home. Based on conflicting accounts from witnesses, the above allegations are resolved as "unsubstantiated". Unsubstantiated means that there is not a preponderance of evidence to determine if an allegation did or did not happen. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward 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 Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: BELLA VISTA WYOMING HOUSEFACILITY NUMBER: 198209658

met_with: Shakisa Henry, Administrotor


raw_content:
Narrative:
There was no evidence that facility staff provide activities for clients in care. Interviews showed instances where staff has taken clients on outings. There was no evidence that facility staff used inappropriate forms of punishment on children in care. Statements in the interviews did not support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred; therefore, the above allegation is Unsubstantiated. There are no deficiencies being cited at this time. Facility cited for violation 80022 (k) The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so. A copy of this report is being left with Administrator, Shakisha Henry.

Investigation Findings:
13On May 15, 2025 at 12pm Licensing Program Analyst (LPA) Donald Martin conducted a collateral visit at N. Taylor Ave Montebello, Ca. 90640 for the purpose of delivering findings for the above complaint investigation which occurred at the above facility. LPA met with Administrator, Shakisha Henry and was allowed into the location. During the investigation of the allegations LPA conducted confidential interviews and collected documentation. The confidential interviews indicated that Staff #2 grabbed Child #1 by the legs and pulled him harshly. Staff #2 was new to the facility and had not been CPI or ProAct trained, but still assisted in a restraint on Child #1, therefore this allegation is Substantiated. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORTCALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B This is an official report of an unannounced visit/investigation of a complaint received in our office on 05/31/2024 and conducted by Evaluator Donald C Martin COMPLAINT CONTROL NUMBER: 34-CR- FACILITY NAME:BELLA VISTA WYOMING HOUSEFACILITY NUMBER: ADMINISTRATOR:HENRY, SHAKISHAFACILITY TYPE: ADDRESS: WYOMING AVENUETELEPHONE: (626) 794- CITY:BURBANKSTATE: CAZIP CODE: CAPACITY:3CENSUS: 0DATE: 05/15/ UNANNOUNCEDTIME BEGAN: 12: PM MET WITH:Shakisha Henry-Administrator TIME COMPLETED:02: PM 9Facility staff spoke inappropriately to youth in care Facility staff did not provide activities for youth in care Facility staff used inappropriate form(s) of punishment INVESTIGATION FINDINGS: 13On May 15, 2025 at 12pm Licensing Program Analyst (LPA) Donald Martin conducted a collateral visit at N. Taylor Ave Montebello, Ca. 90640 for the purpose of delivering findings for the above complaint investigation which occurred at the above facility. LPA met with Administrator, Shakisha Henry and was allowed into the location. During the investigation LPA conducted confidential interviews and reviewed documentary evidence. The interviews did not produce corroborating evidence to support allegations. Interviews revealed inconsistent statements and no witnesses to suggest allegations occurred. There was no evidence that facility staff spoke inappropriately to youth in care. Statements to the contrary were provided to LPA. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: JoAunne Griffin LICENSING EVALUATOR NAME: Donald C Martin LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 2 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION EL SEGUNDO CRP RO, N. Continental Blvd. #290B FACILITY NAME: BELLA VISTA WYOMING HOUSEFACILITY NUMBER: VISIT DATE: 05/15/2025

met_with: Shakisha Henry-Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Connie Jones-Steward met with administrator Shakisha Henry to conduct the annual required inspection. The following was observed. This is a three bedroom, two bathroom home located in the City of Burbank, CA. The back bathroom is under repairs and signed as off limits to clients. There are no security bars on windows, no swimming pools or bodies of water and no firearms on the premises. There is a gated fireplace in the living room. In the kitchen area LPA observed food in supply that meets Title 22 requirements. There is a gas range, refrigerator and dishwasher in working order. All knives, household cleaners and medications are safely stored under lock and key. There is a fully stocked first aid kit. Yard area is free of visible hazards. There is a fully charged fire extinguisher in the kitchen area. There are combination smoke/CO detectors in the hallway and in the bedrooms. Disaster drills are conducted and documented on a monthly basis. All bedrooms have single beds with linens and mattresses in good condition and the required storage space. The following were posted as required: Floor plan, exit signs, notice of personal rights, complaint procedure, and menu. The facility was cited under section 84070 for incomplete immunization records and 80069 for lack of TB test in two of three instances. LPA will review staff records at a later date

met_with: Shakisha Howard Henry


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Connie Jones-Steward met with Facility Manager Teandra Pitts to conduct the annual required inspection. The following was observed. This is a three bedroom, two bathroom home located in the City of Burbank, CA. There are no security bars on windows and no firearms on the premises. Per Ms. Pitts there is an inflatable pool that is currently stored in the garage. The pool is never left with standing water in it and clients are supervised by adults when using the pool. There is a gated fireplace in the living room. In the kitchen area LPA observed food in supply that meets Title 22 requirements. There is a gas range, refrigerator and dishwasher in working order. All knives, household cleaners and medications are safely stored under lock and key. There is a fully stocked first aid kit. Yard area is free of visible hazards. There is a fully charged fire extinguisher in the kitchen area. There are combination smoke/CO detectors in the hallway and in the bedrooms. There is a disaster drill scheduled for 04/27/23 @ 2: PM. All bedrooms have single beds with linens and mattresses in good condition and the required storage space. The following were posted as required: Floor plan, exit signs, notice of personal rights, complaint procedure, and menu. Client records were reviewed and found to be substantially complete. Parents maintain medical rights and are responsible for annual physical exams. LPA will return to review staff records and interview employees. There were no deficiencies cited as a result of this inspection.

met_with: Teandra Pitts, Facility Manager


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst Connie Jones-Steward visited the facility to review the file of C1 in regards to complaints 34-CR-20220720083326, 34-CR-20220714083446. Upon arrival LPA found 2 clients and 1 staff along with two Behavior Support Specialists from Atlas Behavior Services who were there to support C1. Staff number two returned shortly from her break, LPA reviewed the file for C1, the employee schedule and client roster. LPA will contact the administrator for more information,

met_with: Jenisha Henry, DSP 2


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Connie Jones-Steward met with Facility Manager Teandra Pitts & administrator Shakisha Henry to conduct the annual required inspection. The following was observed. This is a three bedroom, two bathroom home located in the City of Burbank, CA. There are no security bars on windows and no firearms on the premises. There is a gated fireplace in the living room. In the kitchen area LPA observed food in supply that meets Title 22 requirements. There is a gas range, refrigerator and dishwasher in working order. All knives, household cleaners and medications are safely stored under lock and key. There is a fully stocked first aid kit. Yard area is free of visible hazards. The inflatable pool is no longer on site. There is a fully charged fire extinguisher in the kitchen area. There are combination smoke/CO detectors in the hallway and in the bedrooms. There is a disaster drill documented on 03/13/2024 at 6: PM All bedrooms have single beds with linens and mattresses in good condition and the required storage space. All windows are operational. The following were posted as required: Floor plan, exit signs, notice of personal rights, complaint procedure, and menu. Client records were reviewed. LPA noted that parental consents for psychotropic medications needed to be updated. Parents maintain medical rights and are responsible for annual physical exams. LPA Jones-Steward will review staff records at a future date.

met_with: Shakisha Henry/Teandra Pitts


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst Connie Jones-Steward visited the facility and met with the administrator to conduct a review of employee records, interview staff and verify correction of deficiency cited on 04/09/2024. LPA interviewed two staff and reviewed two employee record files that were incomplete. LPA observed via board meeting minutes that meetings are being held annually instead of quarterly as required. The licensee was cited under 80066(a) and 84063(a)(8)


summary: Facility Evaluation

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Narrative:
On May 30, 2025 at 9:30 am Licensing Program Analyst (LPA), Justine Armstrong made an unannounced visit to the Facility Bella Vista Wyoming House for the purpose of conducting a Annual/Required visit. Lpa J. Armstrong met with Direct Service Provider, James Buckley who granted access into the facility and a tour of the facility was conducted. The facility is licensed to provide care and supervision to three (3), developmentally disabled children, ages 6-17 years old, ambulatory only. There are no bodies of water on the premises. On this day the census is two (2) children. This is a one-story home equipped with three bedrooms, two bathrooms, living room, kitchen/laundry area, dining area and outdoor space. There is a detached garage that is split in half by a wall one side is used for storage and the other side is used as the staff office. The home is set up as follows: Bedroom #1, Bedroom #2 , Bedroom #3: The rooms is equipped with one full size bed. There is adequate drawers, closet space, and lighting in the room. (See Continued on 809C Bathrooms: There is a total of two bathrooms in the facility. All bathrooms were checked and were in clean operating conditions. Kitchen: There is a stove with five (5) burners, a microwave, air fryer, dishwasher and refrigerator/freezer all working in good condition. The home has plenty of perishable/nonperishable food. The cleaning solutions are made inaccessible to the clients and stored/ locked under the kitchen sink. Next to the kitchen there is also a washer and dryer that stores extra laundry detergent and cleaning solutions that are locked up. There is also a locked medication cabinet in this area with a fire extinguisher. All trash cans have tight lids on. Dining Area: There is a table with two (2) chairs. There are posting of Facility License, facility map, Personal Rights and emergency disatser plan. Living Room: There are two chairs no sofas and a mounted TV. Back Space Area: This area is used as a staff break area with a desk, chair, and fire extinguisher. Garage: The garage space is used for the Facility vehicle and on the other side of the wall is the staff office which has its own door to enter into the office space. LPA Armstrong viewed the vehicle registration which was current. The vehicle is a white clean and safe for transporting clients. Outdoors: The outdoor area is clean there was a bbq grill a trampoline, basketball court, chairs. Overall, the home appears to be clean, safe, sanitary, and in good repair. The home has a first aid kit stored inside one of the locked cabinets where the medication is stored. All knives and sharp objects are kept locked in a box and stored in a locked kitchen cabinet. The hot water was tested and found to be between 105-120 degrees. All smoke detectors and carbon monoxide are operable. There is a working telephone line available for clients to use. The yard is free of debris and hazardous material. There were no deficiencies observed or cited at the time of the visit and a copy of this report will be provided to the facility

met_with: James Buckley


summary: Facility Evaluation

raw_content:
Narrative:
On 6/13/2025 at 9:30 am Licensing Program Analyst (LPA), Justine Armstrong made an unannounced visit to the Facility Bella Vista Wyoming House for the purpose of continuing the Annual/Required visit. Lpa J. Armstrong met with the administrator, Shakisha Henry who granted access into the facility The following was discussed with the facility Administrator: The Facility does not have a Facility Manager. The Administrator stated they are in process of hiring two facilities managers, LPA J. Armstrong will not cite today due to citing the other facility (Bella Vista Zook). The administrator gave LPA J. Armstrong copies of the Facility Manager Job Description/Training Plan. The administrator will email LPA J. Armstrong a new LIC 500 once the Facility Manager background check clears. The facility maintains client cash resources, personal property, and valuables. The children in care are accorded dignity in personal relationships with staff and others. The children live in a safe, healthy, comfortable environment. Lpa J. Armstrong review 2 clients and 3 staff files. Lpa J. Armstrong also reviewed medication of clients/ medication log, Emergency Intervention Plan and Facility car insurance documentation which was in good standing. There were no deficiencies observed or cited at the time of the visit and a copy of this report was provided to the Administrator.


raw_content:
Investigation Findings:
13On December 16, 2025, Licensing Program Analyst (LPA) Justine Armstrong conducted an unannounced visit to Bella Vista Wyoming House to deliver the complaint findings related to the allegations mentioned above. LPA Armstrong met with Shakisha Henry the Administrator, who granted access to the home. During the investigation, all available parties were accounted for. LPA conducted confidential interviews and reviewed documentary evidence such as the Unusual Incident Report, C Needs and Service Plan, and C Individual Education Plan. Staff members denied the allegations and there were no witnesses to suggest that the alleged incidents occurred. While there were some concerns, there was insufficient evidence or testimony to substantiate the allegations. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has decided that the allegation(s) are Unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There were no deficiencies cited. An exit interview was completed, and a copy of this report was provided to the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Enrique M Hernandez LICENSING EVALUATOR NAME: Justine Armstrong LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


facility_name: BELLA VISTA ZOOK HOUSE

raw_content:
Investigation Findings:
13Licensing Program Analyst Connie Jones-Steward investigated the above allegations. LPA spoke with Client #1 and staff. Client #1 was inconsistent in her details about whether or not staff is abusive towards her or if her personal rights are being violated. Based on the inability to obtain supporting evidence, these allegations are resolved as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 2

met_with: Lavetha Oliver


raw_content:
Narrative:
Information obtained during the investigation including confidential interviews of C1, staff members and assigned investigators from outside agencies did not provide enough evidence to support the reported allegation. Interviews revealed no witnesses to the alleged incident and during the time of the alleged incident, Staff member #2 (S2) also present with S1 corroborates C1's bedroom door was open while S1 was present inside C1's room. S2 reported no issues or concerns observed. The allegation was also investigated by South Central Los Angeles Regional Center. The case was closed with a finding of 'not supported' as C1 recanted the allegations. The Department of Children and Family Services reported a history of unsupported allegations and determined the allegation to be inconclusive. Records reviewed revealed no past reprimands or incidents of sexual misconduct for S1. Due to a lack of evidence, it has been determined that the allegation is Unsubstantiated at this time meaning, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred. Exit Interview conducted with Facility Administrator and a copy of this report and appeal rights are emailed to Administrator and also mailed to Licensee.

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

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

met_with: Lavatha Oliver, Facility Manager/Administrator


raw_content:
Investigation Findings:
13Licensing Program Analyst Connie Jones-Steward met with Facility Manager Doreece Claxton to resolve the above allegations. During the course of the investigation, the LPA was unable to receive answers from the complainant that would aid in said investigation. The complainant failed to provide documentation of her allegations or information on the current placement of C1. Therefore C1 was not available for interview. LPA asked for a copy of the client intake for C1 and was informed that no intake was done. That situation will be discussed with the supervising administrator Kim Commadore who is currently out of town. Due to the short period of C1's stay in the home, a needs and services plan was not required. LPA was able to review incident reports showing that C1 was hospitalized several times and after the final time, refused to return to the facility. Based on the above investigation and lack of documentary information, the above allegations are resolved as unsubstantiated. If reasonable people would disagree as to whether the allegation happened, or if the LPA thinks it happened but sufficient evidence cannot be obtained, then the complaint is unsubstantiated, not unfounded. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Connie Jones-Steward LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Doreece Claxton, Facility Manager


raw_content:
Investigation Findings:
13This report is being Amended from the original dated 12/12/2022 in order to correct the citation type on the 9099D page. On December 12, 2022, Licensing Program Analyst (LPA) C. White conducted an unannounced visit to Bella Vista Zook for the purpose of delivering findings on the above allegations. LPA spoke with Administrator, Lavatha Oliver. During the course of this investigation, LPA interviewed pertinent parties, reviewed records, and gathered documentation. Confidential interviews and records produced corroborating evidence to support the allegations. Staff interviews reveal that staff handled client in a rough manner while performing a one-man restraint causing the client injuries. As a result, the staff was terminated from service. Client interview reveal that staff pushed client and injured the client's neck. Based on information obtained, the allegation is Substantiated per California Code of Regulations Title Division Chapter 5. Facility cited for violation of California Code of Regulations, Title Division 6, Chapter 5 regulation 87072(d)(11): Personal Rights. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Charmetha White LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: BELLA VISTA ZOOK HOUSEFACILITY NUMBER: 198209659

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

met_with: Administrator - Lavatha Oliver


raw_content:
Investigation Findings:
13On December 12, 2022, Licensing Program Analyst (LPA) C. White conducted an unannounced visit to Bella Vista Zook for the purpose of delivering findings on the above allegations. LPA spoke with Administrator, Lavatha Oliver. During the course of this investigation, LPA interviewed pertinent parties and reviewed records. Confidential interviews and records did not produce corroborating evidence to support the allegations. Staff stated clients are not denied the use of the restrooms. Staff denied that clients are not treated with respect. Staff denied having knowledge of any staff member emotionally abusing clients. Client interview did not reveal that staff prevented client from using the restroom, that staff emotionally abused client, nor that staff did not treat client with respect. Based on information obtained, the allegations are found to be unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violations did or did not occur. An exit interview was completed, and a copy of this report was left with Administrator. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Charmetha White LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3


summary: Facility Evaluation

raw_content:
Narrative:
During the investigation of complaint 34-CR-20210607151029, LPA Jones-Steward uncovered some record keeping issues that were addressed with Ms. Oliver.


summary: Facility Evaluation

raw_content:
Narrative:
On August 17, 2021 at 2: PM, Licensing Program Analyst (LPA) Regina Martin arrived unannounced at the facility to conduct a Case Management inspection. LPA met with Facility Manager/Administrator Lavatha Oliver for the purpose of obtaining signature on Facility Evaluation report dated July 16, 2021. Signature from the original report was accidentally omitted from first page. During this visit, LPA observed two clients present and two staffs. Administrator states staff #1 no longer works at the facility or for the agency. LPA Martin observed no deficiencies during this visit. A copy of this report was emailed to Administrator during this visit.

met_with: Lavatha Oliver


summary: Facility Evaluation

raw_content:
Narrative:
On August 25, 2021 at 3: PM, Licensing Program Analyst (LPA) Regina Martin arrived unannounced at the facility to conduct a Case Management inspection. LPA met with Facility Manager/Administrator Lavatha Oliver for the purpose of delivering Amended Facility Evaluation Report originally issued on 7/16/2021. During this visit, LPA observed no clients and one staff member present. LPA Martin observed no immediate health or safety concerns during this visit. There were no deficiencies cited at this time. A copy of this report was left with Administrator.

met_with: Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward met with administrator Lavatha Oliver to conduct the annual/required inspection. The meeting commenced at 12: PM and the following was observed. This is three bedroom, 2 bathroom home located in the City of Glendale. There are no bodies of water, no security bars on windows, no firearms and no fire places. In the kitchen area LPA Jones-Steward observed a food supply that meets Title 22 requirements. LPA also observed an electric stove, a fully charged fire extinguisher, and a locked box containing knives and forks. Hot water temperature was 111 degrees. There was a covered trash can. The menu was posted and current . All bedrooms have a single bed with firm mattresses and linens in good condition. There is the required drawer and closet space for each client. The following items were posted as required: employee work schedule, floor plan, exit signs and notice of personal rights and complaint procedure. The last disaster drill was documented as of 03/01/22. Client and staff records are kept at a central location. LPA advised the administrator that client records shall be kept within the facility. LPA will return at a later date to conduct file reviews and interviews. There were no deficiencies cited as a result of this inspection.

met_with: Lavatha Oliver/Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On March 16, 2023, Licensing Program Analyst (LPA) C. White conducted an unannounced Plan of Correction (POC) visit to Bella Vista Zook House for the purpose of clearing a POC. LPA met with Administrator, Lavatha Oliver. The POC was originally cited on 12/12/2022 due to the substantiated complaint allegation: staff handled minor in care in a rough manner causing injuries. The POC was completed on 02/16/2023. During this visit LPA obtained the following: Current CPI certificates for each staff, valid through 03/01/ An exit interview was conducted and a copy of this report and POC letter was provided to the Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward met with administrator Lavatha Oliver to conduct the annual/required inspection. The meeting commenced at 10: AM. Ms. Oliver was the only staff available and she was involved in an online IEP meeting. Therefore LPA conducted the physical plant portion of the inspection solo. The following was observed. This is three bedroom, 2 bathroom home located in the City of Glendale. There are no bodies of water, no security bars on windows, no firearms and no fire places. There were working smoke/carbon monoxide detectors in the bedrooms and in the hallway There are currently 2 clients in placement In the kitchen area LPA Jones-Steward observed a food supply that meets Title 22 requirements. LPA also observed an electric stove, a fully charged fire extinguisher, and a locked box containing knives and forks. Hot water temperature in kitchen and bathrooms was 105 degrees. There was a covered trash can in kitchen. The menu was posted and current . All bedrooms have a single bed with firm mattresses and linens in good condition. There is the required drawer and closet space for each client. The following items were posted as required: employee work schedule, floor plan, exit signs and notice of personal rights and complaint procedure. CARF Certification is valid through August 2024. Client records are on the premises as required. Staff records are kept at a central location. LPA advised the administrator that client records shall be kept within the facility. LPA will return at a later date to conduct file reviews and interviews. There were no deficiencies cited as a result of this inspection.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Connie Jones-Steward met with administrator Lavatha Oliver to complete the annual inspection. 4 employee and 2 client files were reviewed. LPA advised administrator that there were required documents missing from the employee files and an advisory note was issued. Two employees were interviewed. All clients are non-verbal and therefore were not interviewed. There were no deficiencies issued.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst Dahl Larios conducted a case management inspection August 10, 2023, at 10:54 am 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 2 out of 2 youth files were reviewed. 2 out of Direct Care Staff and 2 out of 2 youth were interviewed. (See the Confidential Names List, LIC 811, dated August 10, 2023). The Plan of Operation including policies and procedures 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 Dahl Larios 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 Administrator Lavatha Oliver.

met_with: Administrator Lavatha Oliver


summary: Facility Evaluation

raw_content:
Narrative:
On March 5, 2024 at 10: AM Licensing Program Analysts (LPAs) Rosslyn Gray and Deborah Lee made an announced visit at BELLA VISTA ZOOK HOUSE Group Home y to conduct the Psychotropic Case Medication Inspection. LPAs conducted a Health and safety risk assessment upon arriving at the facility. This case management inspection is conducted pursuant to Health and Safety Code Section 1538.9 (a)(2). During the inspection, LPAs Gray and LPA-Lee met with the Administrator Lavatha Oliver and inspected the facility inside and out. LPAs conducted a brief walk through of the entire physical plant inside and out. LPAs reviewed two (2) of child's psychotropic medications and medication records. LPAs did not interviewed the two (2) children currently prescribed psychotropic medication. C1 and C2 was assessed to be incapable to provide meaningful statements, based on the nonverbal responses. LPAs reviewed three (3) staff personnel files on site at the facility. LPAs interviewed one (1) of staff on site to discuss the facilities policies and procedures of operation. The two (2) other staff were unavailable to be interviewed due to their (NOC) Nocturnal work shift. LPA'S reviewed the LIC500 to confirm the shift which starts in the evening and ends early morning. The Administrator provided a physical hard copy of the psychotropic medication training topics during the training for for LPA's to review. No deficiency were cited per Interim Licensing Standards for Group Home Division Chapter 5. An exit interview was conducted, and a copy of this report was left with the Administrator Lavatha Oliver 16. What is the procedure for transferring prescription medications when children leave the facility on authorized home visits? X Medication is given to the child's authorized representative in a container that is labeled with directions. X Medication is given to the identified responsible adult with a signature upon exiting and returning X Medication is given in original container documented upon departure and return to the facility 17. What psychosocial and other alternative treatments, other than the use of psychotropic medication, does the facility offer children to participate in regularly? X Art X Individual therapy X Life Skills X Music 18. What is the facility's protocol when a child refuses to take their prescription medication? X Explain the pros/cons of taking the psychotropic medication as directed by their doctor to the child X The child's prescribing doctor is contacted about the incident X The child is asked why they are refusing X The child is given time and/or space to rethink their decision X The child's psychiatrist or therapist is consulted about appropriate actions to take X An incident report is filed X Facility staff document the refusal on the MAR or in the child's file YOU HAVE REACHED THE END OF THIS QUESTIONNAIRE! LIC Page 3 of 3