summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analyst Lisa Slusher travelled to the Environmental Alternaves DBA EA Family Services office in Fresno CA. LPA was met by Administrator Kylie Martinez. Agency has an Assigned Administrator/Social Work Supervisor, one social worker and two case managers.. A general overview of their program and a tour of the facility was provided. This facility has a reception area, waiting area, and office space for staff. Fixtures and furniture, equipment and supplies necessary for this operation to be moved from currently licensed location. including locked cabinets for client and staff files in order to ensure confidentiality. Discussed daily ongoing functions including incident reports. There is ample confidential space for meeting with clients on an as needed basis. Incident reports to be emailed to CCLFresnoIncidents@dss.ca.gov. This LPA's email address is Lisa.Slusher@dss.ca.gov. LPA received updated LIC 200 for facility name update during inspection. Agency will ensure that all appropriate personnel are associated to the facility license through Guardian. The above licensee meets the requirements to be licensed as in Fresno County serving participants within a two hour driving radius.


state: CA

facility_name: EA FRESNO THPP/THP+FC

summary: Facility Evaluation

raw_content:
Narrative:
Complaint Specialist C.K. Kinney(CS) traveled to EA Fresno THPP/THP+FC offices and met with Jessica Gomez, and Leticia Serrano to conduct Case Management inspection related to the report of death of a client. CS conducted entrance interview, reviewed documentation and obtained copies, and conducted confidential interviews. No deficiencies observed or cited during this inspection. Copy of this report and LIC Confidential Names left at the agency at conclusion of inspection.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Jessica Gomez, and Leticia Serrano


summary: Facility Evaluation

raw_content:
Narrative:
On September 18,2024, Licensing Program Analyst (LPA) Lisa Slusher conducted an unannounced inspection at the facility at 9: AM. LPA met with Vicky Moreno, Office Manager. The purpose of the inspection was to conduct a Post Licensing inspection at the Foster Family Agency. The agency provides Transitional Housing Services for non-minor dependents at scattered housing sites. A tour of the agency was completed. The office is adequately equipped to provide privacy for interviewing and is conveniently located for the public. Staff files, client files and resource parent files are maintained in a locked room. The license, personal rights, complaint number and emergency disaster plan are posted in plain view. The agency employs one office manager, one Administrator/Social Worker Supervisor, two social workers, two case managers and two transporters. The LPA requested the following items: Personnel Report LIC 500, list of current THP+FC placements.. During today's inspection, LPA Slusher reviewed physical plant, operational requirements, and disaster preparedness. There are no violations of Title 22, Division of 6 of the California Code of Regulations were observed. An exit interview was conducted, and a copy of this report was provided to the FFA representative.

met_with: Vicky Moreno


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, LPAs (Licensing Program Analysts) Lisa Slusher conducted a case management inspection at the above agency. The purpose of this inspection is to address an incident report dated 10/8/24 which was received by the CCLD on 10/23/24. LPA discussed the incident report with Social Worker Christina Cruz See LIC 811 for confidential names A technical violation for section 80061(b) Reporting requirements is issued on this date.

met_with: Christina Cruz


summary: Facility Evaluation

raw_content:
Narrative:
On the above date, Licensing Program Analysts (LPAs), Sonia Sanchez and Miriam Flores arrived at the EA Fresno THPP/THP+FC at N. Fresno St STE 105 in Fresno for the purpose of conducting an unannounced Annual Required inspection. LPA met with Vicky Moreno, Office Manager and Jenna Bethancourt, THP Program Director via phone. A file review was conducted on March 3, 2025, presented 0 deficiencies within the past 12 months. A review of Guardian indicates that all facility staff associated and identified on the LIC500 have eligible clearance. Fire Extinguisher expired on 2/14/2023 and have a scheduled inspection with the Fire Department on 03/07/25. There is 1 inactive apartment, 18 pools available within 9 apartment facilities and no fire arms. At 9AM to 1:00PM - LPAs reviewed staff and client's files. At 1:00PM to 2:00PM - A walk through inspection of the facility was conducted and staff interviews were completed. The Agency currently has THP+FC participants, employs Social Workers, Case Managers, and one full time Administrator. LPAs reviewed Client, and 5 staff files. LPA interviewed Staff. The agency received Technical Advisory.. Exit interview was conducted with Office Manager and Program Director and a copy of the report was provided at the conclusion of the inspection along with appeal rights.

visit_type: Annual

met_with: Vicky Moreno, Office Manager


summary: Facility Evaluation

raw_content:
Narrative:
On December 30, 2025, Licensing Program Analyst (LPA) Olivia Medrano traveled to EA THPP/THP + FC located in Fresno, CA for the purpose of a case management inspection regarding an incident reported to the Department on December 29, 2025. LPA met with Vicky Moreno, Office Manager and conducted a phone interview with Chris Jefferson, the assigned Case Manager and obtained copies of pertinent documentation. No deficiencies were observed or cited on this date and a copy of this report was provided to Vicky Moreno at the conclusion of the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On March 18, 2026, Licensing Program Analysts (LPAs) Olivia Medrano conducted an unannounced inspection at EA Fresno THP for the purpose of conducting a required annual/random inspection. LPA met with Vicky Moreno, Office Manager. The THP currently has Non-Minor dependents placed. The THP currently employs Executive Director/Administrator, Program Director, Social Work Supervisor, Case Managers, and Office Manager. LPA reviewed 4 client files, and 3 staff files. File review indicates that all staff are fingerprint cleared. No deficiencies were issued or observed at this time. The exit interview was conducted and a copy of this report and appeal rights were provided to the THP at the conclusion of the inspection.


facility_name: EMBRACING LIFE'S CHANGES II

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Community Care Licensing also received an allegation that facility staff refused to allow a client (NMD) in care to seek medical attention. It was alleged that NMD could not visit the doctor for a skin rash. Confidential interviews reported that NMD was told by staff they were not allowed to leave to see a doctor for the skin rash. Confidential interviews reported that NMD was responsible for making appointments with doctors, and they were allowed to leave their house when they wanted. Additional confidential interviews reported that NMD was not shown how to make their (NMD) doctor's appointments, which was the reason for not making an appointment for the skin rash. LPA was unable to determine if the allegation occurred due to conflicted statements. Based on inconsistent confidential interviews, the allegations that facility staff (S1) handled the client (NMD) inappropriately and refused to allow the client (NMD) to seek medical attention are unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted, and a copy of this report LIC 9099 and the appeal rights were discussed and provided to Corneisha Hayward, Administrator.

Investigation Findings:
13On December 12, 2024 at 9: AM, Licensing Program Analyst (LPA) Cynthia Robinson conducted an unannounced visit to Embracing Life's Changes II Transitional Housing Placement (THP) to deliver the investigative findings for the allegations listed above. On 08/16/2024, LPA initiated the complaint at THP and obtained documents pertinent to the investigation. LPA interviewed Non-Minor Dependent (NMD), staff (S1, S2, and S3) and County Social Worker (CSW). On 08/12/2024, Community Care Licensing received an allegation that facility staff (S1) handled a client (NMD) in an inappropriate manner. It was alleged that S1 put their hands on NMD. Confidential interviews reported that S1 pushed and grabbed NMD on multiple occasions in response to keep NMD from physically harming themselves. Additional confidential interviews reported that S1 would not grab or pull NMD and would stay out of the way of NMD to avoid getting pushed. The documentation collected reported that NMD was to have 24/7 surveillance due to its high-level care needs. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Cynthia Robinson LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: EMBRACING LIFE'S CHANGES IIFACILITY NUMBER: VISIT DATE: 12/04/2024

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

report_type: Complaint Investigation

met_with: Cornicha Hayward, Administrator

complaint_status: unsubstantiated


summary: Facility Evaluation

raw_content:
Narrative:
A TEAMS Conference Meeting was conducted on September 22, 2022 at 2:00 pm. The purpose of this meeting was a Program Statement Review to discuss the Application/ Program Statement submitted to the Community Care Licensing office. Meeting Attendees: CCL Licensing Program Analyst Darlene Almaraz-Oseguera CCL Manager Natasha Dunlap Facility Administrator Cornicha Hayward Social Worker Shawnte Jenkins President Catherine Ekanem Social Worker Tasha Hayward The topics listed below were discussed during the meeting, Supporting Documents: STAFF · LIC500 does not show qualified Social Work personnel available on 24-hour basis for any emergency. (Title Section 86065 (5). · Missing disaster plan FORMS REVIEW: · LIC 309 - needs to be filled out · LIC 402 - needs to be filled out · LIC 401 (A) - needs to be filled out · LIC 401 - number of clients does not match · LIC 403 - needs to be filled out · LIC 403 (A)- needs to be filled out · LIC 508- missing for the Chief Officer or whoever else is serving capacity · LIC 610 (C) needs to be filled out completely ie. Location and first aid kit. and state that each facility will have one Control of Property: · Missing name and address if owner Plan of Operation: 4. Admission Policies and Procedures Regarding Acceptance of Participants · Missing Compatibility determination process (i.e. perpetrators and predators are not placed together) · Describe the procedures for accepting emergency placements on a time-limited and/or trial basis · Restricted Health Conditions? (Section 80092) Describe restricted health conditions will to accept or not willing to accept. Address additional training/staff if applicable . Completing Restricted Health Condition Care Plan · What are the participant's responsibilities in the event of an emergency? · Provide a list of staff responsible for intake and what their role is in the process. · Ensure there is no discriminating against a certain population based on, Sexual orientation gender identity or expression (i.e. will not work with transgender, gay, lesbian youth) Race/Ethnicity/Culture Health Related · Description of how THPP staff shall ensure that participants receive necessary first aid, medical, dental, vision, and mental health care, and related services. · How THPP staff will assist a NMD with developing skills necessary for self-sufficiency in obtaining health services. · How THPP will assist participants with prescription or nonprescription medication administration and injections upon request. · How THPP will obtain permission by participant's physician. · How THPP will ensure proper storage of medications and injections to ensure health and safety of all participants. · If a participant cannot determine his/her need for medication, what shall the THPP do to ensure medication administration and monitoring as required? PERSONAL RIGHTS · Description of how the THPP will ensure the protection of the participant's personal rights (according to W&I 16001.9, Title Section 86172, and Title Section 86072, as applicable.) · Policies and procedures for promoting and ensuring the personal rights of participants · Plan to have the Foster Youth Bill of Rights and information about the Foster Care Ombudsperson always fully visibly posted without obstructions in areas accessible to participants in the THPP offices and sub-offices · Procedures for having conversations around personal rights during N&S plan discussions. · Procedures to discuss personal rights upon intake · Procedures to check-in with participants to remind them of their personal rights as necessary · How participants and authorized representatives will be advised of personal rights and the ability to file complaints · Procedure to provide participants and authorized representatives copies of personal rights 5. Admission Agreement/ Participant Contract (Missing) · Procedures for separate admission agreements Between the placing agency and the THPP · Contract between the THPP and the participant. · Procedures for admission agreements for participants versus NMDs including modifying the admission agreements · The licensee shall complete and maintain in the participant's file a Telecommunications Device Notification form (LIC 9158, 5/97) for each client whose pre-admission appraisal or medical assessment indicates he/she is deaf, hearingimpaired, or otherwise disabled · The admission agreement(s) is missing, Basic services Available optional services, Payment provisions, including the following: Basic rate , Optional services rates, Payor, Due date, Frequency of payment, Modifying conditions required at least 30 calendar days prior written notice to the client or his/her authorized representative of any basic rate change. Acceptable for agreements with children whose care is funded at government rates to specify that the effective date of a government rate change shall be considered the effective date for basic service rate modifications and that no prior notice is necessary. · Refund conditions · Right of the licensing agency to perform the duties authorized in Section 80044(b) and (c) · Conditions under which the agreement may be terminated 6. Administrative Organization: · Missing Constitution and by-laws do not violate licensing regulations · Missing Board of Resolution submitted designating authorized signatory · Missing Directors' and officers' names, titles, business and phone numbers listed · Missing Board meets quarterly · Missing Board of resolution designating the administrator 8. Sketch(es) of Building(s) · Missing a sketch of the buildings and grounds for each facility included , Administrative Office, Subadministrative Office, Single Site Model location, Dimensions of all rooms and designated, Facility sketch with emergency exits designated 9. Transportation Arrangements · Missing statement that smoking policy even when transporting NMDs 10. Safeguards for Cash Resources, Personal Property & Valuables · Describe how the THPP accounts for and handles participant's personal funds, personal property, and valuables (i.e. emancipation funds). · Policy for NMDs shall be consistent with Transitional Independent Living Plan. · Shall allow for NMD to request assistance in managing cash resources, personal property and/or valuables. · THPP staff maintains accurate records of NMD's bank account, savings, and monthly budget when requested by participant. · THPP staff shall not make expenditures from the cash resources of a NMD for any basic services. · IF THPP has been entrusted, how will items be surrendered to NMD/responsible party upon leaving the THPP (Inspection, signing, receipt, etc.) 11. Consultant and Community Resources · Some Community Partners could include, Tribes, Mental Health Providers, Local Law Enforcement, Schools, Courts/Attorneys Program Statement: 1. Program Goals: · The "How/Implementation" is addressed, not just stated 2. Description of Youth to be Served · Did not mention SOGIE (Sexual Orientation, Gender Identity and Expression) 3. Admission Criteria · Describe the policies and procedures for admitting clients, including, Compatibility determination process (i.e. perpetrators and predators are not placed together) (Pre-Placement Appraisal as necessary), Input from the child and family team · Needs and services plan · Transitional Independent Living Plan (TILP) · Personal rights · How THPP will ensure that each applicant receives all necessary medical, dental, vision and mental health services. · Emergency information including how participants can reach a staff member after hours, on weekends and holidays. · What are the participant's responsibilities in the event of an emergency? · Provide a list of staff responsible for intake and what their role is in the process. · Describe the procedures for accepting emergency placements on a time-limited and/or trial basis (if applicable). · Ensure there is no discriminating against a certain population based on: Sexual orientation gender identity or expression (i.e. will not work with transgender, gay, lesbian youth), Race/Ethnicity/Culture 5. Staff/Volunteer Training Plan · What qualified consultants shall be employed or retained to implement the plan of operation? · How will THPP have qualified social work personnel available on a 24-hour basis to respond to emergencies? · Training for all staff shall include, but not limited to: · Reporting requirements (procedures for 24- hour, seven day written, and six months follow up as applicable) · Reporting requirements for NMDs (24-hour, seven day written, and other applicable reporting requirements), Child abuse identification; Trauma informed services ; Culturally relevant service and supports · Did not mention volunteer? 6. Monitoring THPP Participants · Procedure for determining bedroom sharing arrangements for minors and NMDs. · Procedures for conducting criminal record clearance/exemption requirements for adult roommates/individuals living with minor participants. · What rules, including discipline, are different for: Youth still in the foster care system vs Youth no longer in the foster care system but participating in the THPP. · Description of THPP expectations, alternatives, and consequences policies and procedures applicable to NMDs ONLY. (ILS 86172.1) Reasonable and temporary consequences for noncompliance with reasonable expectations · How THPP will inform NMD when it is necessary to impose alternatives or consequences including discussion and opportunity to choose the appropriate alternatives or consequence. · How THPP will develop a plan including time limit(s) Document the decision to subject NMD to the chosen alternative or consequence and steps taken in subjecting NMD to alternative or consequence. 7. Procedures for Responding to Complaints and Emergencies on a 24-hour Basis · How the THPP plans to respond to disasters (i.e. earthquakes, fires, floods, etc.). Protocol for notifying participants' authorized representative(s) and licensing of participant whereabouts and condition. · Communication protocol among THPP staff and local fire, law enforcement and other disaster authorities. 8. Allowance Procedures · Procedures for determining the amount of allowance provided to each participant · Schedule of disbursement. · Allowance shall be sufficient for the participant to purchase food and other necessities. 9. Utilities, Telephone, Rent Payments and Monitoring Procedures · Consequences for participants who are unwilling or unable to meet financial obligations · Consequences for participants' behavior when disruptive to the program/infringes on rights of other participants in the program. 10. Program Policies · Approval of any nonparticipant roommates. · A linkage to the Federal Workforce Investment Act of 1998 program administered in the local area to provide employment training to eligible participants. · Consequences for participants who are unwilling or unable to meet financial obligations · Consequences for participants' behavior when disruptive to the program/infringes on rights of other participants in the program. 11. Living Unit Furnishings · Procedures of cleanliness of Units 12. Participant Records · Description of the records to be maintained by minor participants including; certified birth certificate, social security card, CA or other state identification cord or driver's license, proof of citizenship or residency status, death certificate(s) of parent(s) if applicable, proof of county dependency status for education aid applications, school records, immunization records, medical records, Health and Education Passport, work permit, written information concerning minor's dependency case including information about youth's family history, the child's placement history, names, phone numbers and addresses of siblings and other relatives, information regarding jurisdiction termination hearing and the potential consequences of a failure to attend the participant's birth certificate if available. · Persons to be contacted in an emergency when the participant's authorized representative cannot be contacted. · Name, address and phone number of current employer. · Written consent for emergency medical and dental care · Prohibited individuals. · Religious preference including religious advisor or clergyman as applicable. · Copy of the N&S/TILP and modifications. · Record of the continuing health needs and services received while the participant is in the THPP (i.e. physical therapy and counseling) · Description of what records THPP will assist in obtaining for participants/NMDs, including: Health and education information and records, including mental health information or records (W&I 16010); Needs and Services Plan and Transitional Independent Living Plan (TILP) ; Itemized inventory of cash resources, personal property, and valuables if entrusted. ; Signed copy of the written removal or discharge policies and procedures. ; Other records as requested by participant including: certified birth certificate, social security card, CA or other state identification cord or driver's license, proof of citizenship or residency status, death certificate(s) of parent(s) if applicable, proof of county dependency status for education aid applications · Personal Rights (signed acknowledge receipt) Expectations, alternatives, and consequences for living in the THPP · Policy for dispersing participant's and the participant's child(ren)'s records. 13. Education Options · How THPP shall allow access to information regarding available vocational and post-secondary education options (W&I 16001.9(a)(26) 15. Reporting Requirements/ Incident Reporting/Law Enforcement Involvement/ Child Abuse Reporting · Policies and Procedures for notification to Participant's Authorized Representative and Placement Entity when; Incident Reports , Relocation is necessary , Removal under emergency circumstances , Incidents reported to licensing agency (80061(B)(1)(A)) , Unexplained absences, Any event threatening the health & safety of participants , Administrator Change, Death of NMD Injury/Illness requiring emergency medical treatment/hospitalization , Prolonged absences lasting more than 72 hours (NMD) , Poisoning/Fires/Explosions · Policies Regarding Child Abuse/Neglect Reporting Child Abuse Reporting Requirements (Penal Code 11164) (physical, emotional, psychological, or suspected abuse, as required) · THPP's policies and procedures regarding child abuse reporting including notifying the authorized representatives and licensing agency · Procedures for employees to report child abuse or other abuse of participants · Procedure on documentation and storing of the abuse reports · Ensure the procedure does not violate the law (i.e. require staff to report to a supervisor before reporting to law enforcement). 16. . Self Sufficiency · Description of how the licensee or THPP staff shall assist with development of skills necessary for selfsufficiency including, but not limited to: Financial literacy , Nutrition and health food choices, grocery shopping, food and meal preparation , Identifying a suitable home and home maintenance , Child Care , Clothing assessment and obtaining minimum required , Automotive maintenance , Educational and career development , Obtaining medical, dental, vision and mental health care, Access to community resources , Developing and reaching goals, Self-care, including performing the nonminor dependent's own laundry (wash, dry and ironing), Drug and alcohol abuse awareness and prevention , Safe sex and reproductive health information. · Policies for ensuring that nonminor dependent parent provides care and supervision for their own child(ren) · THPP staff encourages participants to participate in household duties and other tasks at the THPP · Unless otherwise restricted, encourage participants to select, seek and maintain permanent connections between participants and the family, non-relative extended family members and other caring and committed adults. 17. Certificate of Compliance · Description of model(s) to be used by THPP Host Family Model or Staffed Site Model or Remote Site Model · Remote Site Model description of the written plan to ensure at minimum the following; Utilize provisions for safe and adequate services, Not be detrimental to the health and safety of participant(s) , How THPP will provide support through alternate and supplemental services, procedures, techniques, personnel and staffing ratios that provide equal health and safety measures , How the THPP will assess the individual characteristics and maturity of the participant(s) for placement in this model. · Procedures for cosigning leases with nonminor dependents - no participant can solely sign a lease or rental agreement. · Procedures for documenting that the single housing unit meets the requirements as specified and may be used as living quarters for THPP participants. · Personnel responsible for ensuring compliance and producing "Certificate of Compliance". 18. Core Services · Description of how THPP will make available core services either directly or through secured agreements with other agencies.

met_with: Cornicha Hayward


summary: Facility Evaluation

raw_content:
Narrative:
On January 06, 2023, at 9:00am, Licensing Program Analyst (LPA) Darlene Almaraz-Oseguera conducted an announced pre-licensing inspection at the facility agency's administrative office located at Lime St. BLDG #2 #216, Riverside, Ca. 92501. LPA met with Administrator, Cornicha Hayward, Director Tasha Hayward and was given a tour of the facility. Upon entrance into the facility, there is a multiple business with private suites. There spacious open area with a large table that leads to each individual suites. There is one office that is equipped with a desk, locked file cabinet and printer/scanner. Records: Client files will be locked in the office. There is a staff break room equipped with refrigerator and microwave downstairs in the building. The restroom are located inside the building upstairs and downstairs. The conference room is equipped with a table, chairs, white board and file cabinets and television. The facility has Wi-Fi accessibility. The facility meets the Regulatory requirements and is ready for licensor at the conclusion of the visit. Exit interview conducted. A copy of this report was given to the Applicant

visit_type: Prelicensing

met_with: Cornisha Hayward


summary: Facility Evaluation

raw_content:
Narrative:
On May 10, 2023, at 8:40am, Licensing Program Analyst's (LPA's) Darlene Almaraz-Oseguera, Emina Preciado, and Jason Dalton conducted an announced post-licensing inspection at the facility agency's administrative office located at: Lime St. BLDG #2 #213, Riverside, CA 92501. LPA met with Administrator, Cornicha Hayward, and was given a tour of the facility. The facility as three remote sites, two in the city of Riverside and one in the city of Los Angeles. There are no placement's in the remote sites at this time. Upon entrance into the facility, there are multiple business with private suites. There spacious open area with a large table that leads to each individual suites. There is one office that is equipped with a desk, locked file cabinet, and printer/scanner. Records: Client files will be locked in the office. There is a staff break room equipped with refrigerator and microwave downstairs in the building. The restroom are located inside the building upstairs and downstairs. The conference room is equipped with a table, chairs, white board, file cabinets, and television. The facility has Wi-Fi accessibility. The facility meets the Regulatory requirements and is ready for licensor at the conclusion of the visit. LPA reviewed two staff files and both met the minimum qualifications and training requirements. A review of records shows that all staff have FBI, DOJ, and Child Abuse Index Check clearances. The facility has no placement's at this time and has not had any since being licensed. Exit interview conducted and a copy of this report was given to Cornicha Hayward.


summary: Facility Evaluation

raw_content:
Narrative:
On January 23, 2024, at 9:07 am, Licensing Program Analyst (LPA), Emina Preciado, conducted an announced visit at Embracing Lives Changes II, administrative office, located at: Lime St. Building # Suite #213, Riverside, CA 92501. The purpose of the visit was to conduct a required annual inspection. LPA met and did a walk through of the facility with, Administrator, Cornicha Hayward. Upon entrance into the facility, there are multiple businesses with private suites. There is a spacious open area with a large table that leads to each individual suite. There is one office that is equipped with a desk, locked file cabinet, and printer/scanner. The facility has Wi-Fi accessibility. Facility, participant, and personnel records are stored in a locked file cabinet. There is a staff break room located in the building, downstairs, that is equipped with a refrigerator and microwave. Restrooms are located inside the building both upstairs and downstairs. There is a conference room that is equipped with a table, chairs, white board, file cabinets, and television. There are currently six participants in five remote sites. Four of the remote sites are located in Riverside county and one in San Bernardino county. Remote sites are no further then two hours distance from the Administrative office location. Staff was informed that each Social Worker should maintain a 1 to 12 ratio, which should never be exceeded. Staff is aware of submitting unusual incident reports, as needed, to the Department and to include all Law Enforcement contacts. During the inspection, LPA reviewed six participant records and five personnel records. Five out of five personnel records reviewed met the minimum qualifications and training requirements. A review of records shows that all staff have FBI, DOJ, and Child Abuse Index Check clearances. Five out of five personnel records reviewed had a completed Tuberculosis (TB) test but did not have a health screening on file. * LIC 809-C* Six out of six participant records had required documents including admission agreement, personal rights, medical/education history, immunization records, and medical consent forms on file. Six out of six participant records reviewed had a completed Transitional Independent Living Plan (TILP) on file but did not have a completed Needs and Services Plan (NSP) on file. Based on observation and record review, the facility is being cited for California Code of Regulations (CCR) section 86066(a)(11) and Title 22, Interim Licensing Standards (ILS) section 86268.3(a) which poses a potential health, safety, and personal rights risk to clients in care. Technical violations were given to the facility with a plan of correction and due dates. Exit interview conducted, appeal rights were discussed and provided. A copy of this report along with LIC 809D was provided to Cornicha Hayward, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On January 30, 2025, at 9:30 am, Licensing Program Analyst (LPA), Cynthia Robinson, conducted an unannounced visit at Embracing Lives Changes II. The purpose of the visit was to conduct a Annual Random inspection. LPA met and did a walk through of the facility with, Administrator, Cornicha Hayward. Upon entrance into the facility, there are multiple businesses with private suites. There is a spacious open area with a large table that leads to each individual suite. There is one office that is equipped with a desk, locked file cabinet, and printer/scanner. The facility has Wi-Fi accessibility. Facility, participant, and personnel records are stored in a locked file cabinet. There is a staff break room located in the building, downstairs, that is equipped with a refrigerator and microwave. Restrooms are located inside the building both upstairs and downstairs. There is a conference room that is equipped with a table, chairs, white board, file cabinets, and television. There are currently fifteen participants in five remote sites. Four of the remote sites are located in Riverside county and one in Los Angeles county. Remote sites are no further then two hours distance from the Administrative office location. Staff was informed that each Social Worker should maintain a 1 to 12 ratio, which should never be exceeded. Staff is aware of submitting unusual incident reports, as needed, to the Department and to include all Law Enforcement contacts. During the inspection, LPA reviewed five participant records and five personnel records. Five out of five personnel records reviewed met the minimum qualifications and training requirements. Five out of five personnel records reviewed had a completed Tuberculosis (TB) test and a health screening. (Continued on LIC 809C.. ) Five out of five participant records had required documents including admission agreement, personal rights, medical/education history, and immunization records. Five out of five participant records reviewed had a completed Transitional Independent Living Plan (TILP) and a completed Needs and Services Plan (NSP) on file. Five out of five participants did not have a physical. Please see 809-D for citation. Exit interview conducted, appeal rights were discussed and provided. A copy of this report along with LIC 809-D was provided to Cornicha Hayward, Administrator.


raw_content:
Narrative:
On 09/26/2025, Community Care Licensing (CCL) received an allegation that staff (S1) did not allow non-minor dependent (NMD) access to funds. Confidential interviews reported that NMD received the funds one day later. Confidential interviews indicated that the facility will encourage participants to maintain a clean living space to avoid conflicts with roommates and to tend to their living environment. Based on inconsistent confidential interviews and documentation review, the allegations that staff (S1) inappropriately speak to non-minor dependent (NMD) and staff (S1) did not allow non-minor dependent (NMD) access to funds are unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of evidence to prove that the alleged violations occurred. A copy of this report and appeal rights were provided to Administrator, Cornisha Hayward. **The purpose of this form is to make Public. Signatures will be held in physical file.*

Investigation Findings:
13*The purpose of the amendment is to make this form Public. Signatures will be held in physical file.* On March 5, 2026, at 8:45AM, Licensing Program Analyst (LPA) Cynthia Robinson conducted an unannounced visit to Embracing Life's Changes II, Transitional Housing Placement Program (THPP), and met with Administrator, Cornisha Hayward to deliver the investigative findings for the allegations listed above. On 10/02/2025, LPA Robinson initiated the complaint and obtained documents pertinent to the investigation. LPA interviewed the Non-Minor Dependent (NMD), Staff (S1 and S2), and the County Social Worker (CSW). On 09/26/2025, Community Care Licensing (CCL) received an allegation that staff (S1) inappropriately speaks to non-minor dependent (NMD). It was alleged that S1 threatens NMD with the status of their placement. Confidential interviews reported that S1 speaks inappropriately to NMD at all times, with no specific incident noted. Confidential interviews reported that S1 denied speaking to NMD inappropriately. (Continued on LIC 9099C...) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Cheraki Davis LICENSING EVALUATOR NAME: Cynthia Robinson LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 19-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION RIVERSIDE CRP RO, MAIN ST., SUITE FACILITY NAME: EMBRACING LIFE'S CHANGES IIFACILITY NUMBER: VISIT DATE: 03/05/2026

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

met_with: Administrator Cornicha Hayward


facility_name: EMPOWER MENU

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an announced pre-licensing inspection at the agency and met with Executive Director Michel Douglas who assisted with the inspection. LPA conducted a walk through of the agency with ED. The office is located in a commercial office building, with other businesses present. There are two rooms in the office with space for private interviews/meetings. There was a locked safe for files, chairs, a desk, and shelving. The business hours are not yet posted on the door. Needed before Licensure: To be submitted to CCL by Friday 12/13/2024. 1. For Administrator, ED will submit the following: - Proposed Administrator's proof of education that meets the requirements. - Proposed Administrator's Resume, and employment verification. - LIC 501. 2. ED will also transfer proposed Administrator's fingerprint clearance to the new license number to associate. 3. An Emergency Disaster plan is needed. LPA provided HSC1565 to ED for review so she can write this plan. 4. Hours of the business will be posted on the exterior door of office, along with a contact number for someone who can respond to visitors if they are not present. An exit interview was conducted with ED and a copy of this report was provided to her.

met_with: Michel Douglas


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an announced Pre-Licensing follow up inspection at the facility and met with CEO Michel Douglas who assisted with the inspection. At the previous inspection, the following items were needed: 1. For Administrator, ED will submit the following: - Proposed Administrator's proof of education that meets the requirements. - Proposed Administrator's Resume, and employment verification. - LIC 501. 2. ED will also transfer proposed Administrator's fingerprint clearance to the new license number to associate. 3. An Emergency Disaster plan is needed. LPA provided HSC1565 to ED for review so she can write this plan. 4. Hours of the business will be posted on the exterior door of office, along with a contact number for someone who can respond to visitors if they are not present. The licensee submitted all items required, is working on transferring the Administrator's fingerprint clearance, and the hours of the business have been posted on the door as required. This location is approved to be licensed. Licensee will submit their Program Statement updates to CCL within 60 days by 3/23/2025. All updates will be highlighted for review. An exit interview was conducted with Licensee, and a copy of this report was provided to her.


facility_name: XTENDED MENU

summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an announced pre-licensing inspection at the facility and met with Executive Director and Administrator (ED), Kimberlee Espadron and Social Work Supervisor (SWS) Michel Douglas, who assisted LPA with the inspection. The facility is located in an office building, shared by other businesses. The office space is one room, equipped with a file cabinet which will confidentially hold client and staff files. A restroom is located in the building. The room can provide space for confidential interviews, providing others in the room leave. LPA completed Component Three of the licensing process with ED and SWS by reviewing regulation and processes with them. LPA collected updated LIC forms and the final program statement. ED updated LIC308, LIC309, LIC400, LIC200, LIC999, as well as updated their Program Statement section - Transportation. ED updated the Emergency Disaster plan section to include all required information, LPA collected a copy of this. Topics reviewed: Fingerprint clearances, Guardian, LPA inspections, citation/advisory note process, civil penalty types, CARE tools, CDSS forms and how to find them, exceptions and waivers, ACLs, ACINs, PINs, Certificates of Compliance, reporting requirements, reporting units and phone numbers, inspection authority, POCs, extensions on POC due dates, social worker/social work supervisor ratios, client access to telephones, personal rights, AB ILS and THPP specific regulations. The facility does have a facility phone, it is a cell phone, which they will leave in the office and keep it charged at all times. On-site at the remote location, they have a landline phone that connects to the wifi. On this date, the facility is ready to be licensed and LPA will issue the license to ED and SWS. LPA and ED/SWS will keep in communication about minor changes/updates to be made to their Program Statement. An exit interview was conducted with ED and SWS and a copy of this report was left with them.

met_with: Kimberlee Espadron & Michel Douglas


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess and Licensing Program Manager (LPM) Jodean Hall met with Licensees Michel Douglas and Kimberlee Espadron via Microsoft Teams to discuss their plans for their license. Licensees Espadron and Douglas wish to separate and be licensed separately. Options given were: 1. to maintain their current license and open a different location, however the board will still be accountable for all. 2. Surrender license and apply for two more licenses separately. Licensees initially started as a partnership and are currently a corporation, however the financial information was under an individual, rather than the corporation. If Licensees choose to stay intact with the corporation, and to submit a new application for a second THPP, the Licensees will need to submit a Board Resolution stating agreement with their plans. Licensee will also correct the financials through the corporation. Licensees can change their facility names if they so choose. CCL will work with the Licensees to correct the current program statement if Licensees choose to keep it, and assist with the potential new program statement. LPM informed Licensees how to proceed whether they completely separate, choose to stay under the same corporation, or one licensee takes over the license and the other branches off with their own separate application. Licensees will inform CCL how they would like to proceed by 8/1/2024, and CCL will assist them through that process. An exit interview was conducted with the licensees and a copy of this report was emailed to them with a read receipt. Licensees will sign the document and return it to LPA.

met_with: Michel Douglas & Kimberlee Espadron


summary: Facility Evaluation

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Narrative:
Licensee Michel Douglas made an announced visit to CCL's office to review Program Statements with LPA Alyssa Burgess. During this meeting, Licensee and LPA discussed other program changes that are in process with Xtended Menu: Licensee provided LPA with a Board Resolution which changed the Corporation name from "Xtended MEnU, Inc.", to "Empower MEnU, Inc.", as well as Secretary of State documents with the name change. The Resolution did not include a facility name change approval, so Licensee stated she will have that to LPA by COB tomorrow 9/20/2024. Licensee asked LPA questions about forms she will submit to CCL for the change of location and Administrator. LPA reviewed these with her, as well as what else needs to be submitted for the name change, relocation for the facility, and Administrator designation. LPA also reviewed with Licensee how to complete the facility sketch form. Licensee gave CCL the relocation fee check during today's office visit, and will submit the rest of the documents by COB tomorrow 9/20/2024. Licensee provided LPA with a Board Resolution to elect a new Chief Financial Officer. LPA reviewed requirements with Licensee to ensure herself and her Board Members review and fill out the acknowledgement (LIC 9165) from the "Facts You Need To Know" Booklet (PUB 326) and maintain that record in their files. Licensee will also send CCL a copy of those acknowledgements. LPA will process the Corporation Name Change when the other documents from the resolution are received. Needed for Change of Location: 1. LIC FORMS: 200, 999,610, 9045, 500, 400, 401, and 308. 2. Lease agreement for the new location. 3. Check with the relocation fee of $454 (RECEIVED). ** An updated Program Statement/Plan of Operation will be submitted by Licensee to CCL within 60 days of relocation licensure. Once relocation is completed, LPA will give Licensee the correct due date. Needed for Change in Administrator: 1. Proposed Administrator's proof of education that meets the requirements. 2. Proposed Administrator's Resume. 3. LIC 501. An exit interview was conducted with Licensee and a copy of this report was provided to her.


facility_name: ENNEAD THPP/NMD

summary: Facility Evaluation

raw_content:
Narrative:
On February 3, 2022, from 9:00AM to 11:30AM Licensed Program Analyst, Yuvi Diaz (LPA) and License Program Manager, Rosa Rodriguez (LPM) conducted a virtual meeting via Teams with Jason Cunningham, CEO and Mehwish Khan, Administrator. The purpose of this meeting was to conduct Component II of the application. LPA Diaz and LPM Rodriguez went over the following sections of the Program Statement with the applicants: Application for a Community Care Facility (LIC 200), Orientation Certificate, THPP for minor foster children and Nonminor Dependents, Applicant Information (LIC 215), Administrative Organization (LIC 309), Affidavit Regarding Client Cash Resources (LIC 400), Surety Bond (LIC 402), Monthly Operating Budget (LIC 401), Supplemental Financial Information (LIC 401A), Balance Sheet (LIC 403), Balance Sheet Supplemental Schedule (403A), Financial Information Release and Verification (LIC 404), Personnel Report (LIC 500), Personnel Record (LIC 501), Health Screening Report - Facility Personnel (LIC 503), Criminal Record Statement (LIC 508), Emergency Disaster Plan (LIC 610C), Control of Real Property Application or Documentation of Accreditation (not required for THPP), Administrative Office and Subadministrative Office Location(s), Admission Policies and Procedures Regarding Acceptance of Participants, Health Related Services Personal Rights, Admission Agreement/ Participant Contract, Administrative Organization, Staffing Plan, Sketch(es) of Building(s), Report Continues on LIC 809-C Transportation Arrangements, Safeguards for Cash Resources, Personal Property & Valuables, Consultant and Community Resources, Family Visitation Policies, Program Goals, Description of Youth to be Served, Admission Criteria, Removal Policies and Procedures, Staff/Volunteer Training Plan, Monitoring THPP Participants, Procedures for Responding to Complaints and Emergencies on a 24-hour Basis, Allowance Procedures, Utilities, Telephone, Rent Payments and Monitoring Procedures, Program Policies, Living Unit Furnishings, Participant Records, Education Options, Needs And Services Plans/ Transitional Independent Living Plans (TILP), Reporting Requirements/Incident Reporting/Law Enforcement Involvement/ Child Abuse Reporting, Self Sufficiency, Certificate of Compliance, Core Services and Supports Applicants will have the final revisions completed and submitted to LPA Diaz by February 18, 2022. Component III has been scheduled for March 4, 2022. LPA Diaz and LPM Rodriguez thanked applicants for their time.

met_with: Jason Cunningha and Mehwish Khan


summary: Facility Evaluation

raw_content:
Narrative:
On March 4, 2022 at 9:22am, Licensed Program Analysts (LPA) Yuvi Diaz, and Jacqueline Carmona and License Program Manager (LPM) Rosa Rodriguez conducted a Pre-Licensing inspection and the Component III during today's inspection. LPAs and LPM toured the facility. Facility is a single home and consists of two bedroom, two bathrooms, living room, kitchen, dining room, and small backyard. Fire alarms and carbon monoxide were tested. First aid kit was checked and complete. Upon the inspection, LPAs and LPM found out that Executive Director is living in the Administrative Office/home. LPM informed the ED that ED was not allow to live in the home once the home was licensed as the THPP Administrative Office. The Executive Director and Administrator informed the LPAs and LPM that they will find an office location for the Administrative Office instead. Once the new office is rented, they will notify the LPA and submit all the revised required forms with the new address. LPAs and LPM went over the Children Records forms and Personal Records forms to ensure the applicants know which forms they are required to use. Once Executive Director and Administrator find an office location LPA will conduct another Pre-Licensing inspection to the new location. Care Tool was completed.The following domains were completed:physical plant, operations, disaster, and preparedness. An exit interview was conducted with Executive Director, Jason Cunningham, and Administrator, Mehwish Khan. A coy of this report was emailed.

met_with: Jason Cunningham, Executive Director, and Mehwish Khan, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On March 25, 2022 at 10AM License Program Analyst (LPA) Yuvi Diaz conducted a Pre-Licensing inspection. LPA Diaz met with Jason Cunningham, Executive Director and Mehwish Khan, Administrator who assisted with this inspection. LPA toured the new location. Administrative office is located in a two story building. Upon entering the building there is a receptionist area, to right there is a stair case the leads to the second floor, the left side also has a stair case that leads to the second floor, there are 4 exit doors, fire extinguishers are up to date. there are public restrooms in the building, and two conference rooms that can be used for private meetings. The suite has two desk with computers, locked file cabinet where private files will be kept, two sitting chairs, table, and first aid is stocked. The building and suite are clean, safe, and sanitary. The conference room have a code to get into for privacy. LPA Diaz was unable to open pre-licensing report because pre-licensing was initiated on a different location. An exit interview was conducted with Executive Director, Jason Cunningham, and Administrator, Mehwish Khan. A coy of this report was emailed.


summary: Facility Evaluation

raw_content:
Narrative:
On July 27, 2022 at 1:37PM License Program Analyst (LPA) Yuvi Diaz conducted a Post-Licensing inspection. LPA Diaz met with Jason Cunningham, Executive Director and Mehwish Khan, Administrator who assisted with this inspection. LPA toured the Administrative office is located in a two story building. Upon entering the building there is a receptionist area, to right there is a stair case the leads to the second floor, the left side also has a stair case that leads to the second floor, there are 4 exit doors, fire extinguishers are up to date. there are public restrooms in the building, and two conference rooms that can be used for private meetings. The suite has two desk with computers, locked file cabinet where private files will be kept, two sitting chairs, table, and first aid is stocked. The building and suite are clean, safe, and sanitary. The conference room have a code to get into for privacy. The following following documents were posted: COVID- Poster, License, Personal Rights, and Emergency Disaster Plan. At this time the facility has no placement's. All posting requirements are met and all appropriate forms will be used once there are participants. An exit interview was conducted with Executive Director, Jason Cunningham, and Administrator, Mehwish Khan. A coy of this report was emailed.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Yuvi Diaz made an unannounced annual inspection on March 21, 2023, at 10:30AM. During the inspection LPA Diaz met with Jason Cunningham, Executive Director and Mehwish Khan, Administrator who assisted with this inspection. LPA Diaz conducted a walk through the administrative office is located in a two-story building. Upon entering the building there is a receptionist area, to right there is a staircase the leads to the second floor, the left side also has a staircase that leads to the second floor, there are 4 exit doors, fire extinguishers are up to date. there are public restrooms in the building, and two conference rooms that can be used for private meetings. The suite has two desks with computers, locked file cabinet where private files will be kept, two sitting chairs, table, and first aid is stocked. The building and suite are clean, safe, and sanitary. The conference room have a code to get into for privacy. The following documents were posted: COVID- Poster, License, Personal Rights, and Emergency Disaster Plan. At this time the facility has five placement's. LPA Diaz inspected and/or reviewed the following: Physical Plant: Posting of license, Personal Rights, First Aid Kit fully stocked, administrative office is within two hours of participants living areas, files are in a secure area, and has an area for private interviews or meetings Operations: Board minutes reviewed, plan of operations reviewed, certificate of compliance reviewed, and register of participants reviewed. Disaster Preparedness: Disaster and mass casualty plan updated and available. Quarterly Drills conducted and documented. Disaster preparedness supplies verified. Staffing/Volunteers: Number of Staff files reviewed two, Executive Director and Administrator. Criminal record clearances verified. First Aid Certificate, Certified Administrators certificate valid and current, Job title/qualification verified, and Hours required training verified. Client Records: LPA Diaz reviewed four client records. Current needs and service plan with all the information required. Medical history and TLP. The following items were reviewed for compliance in the regional office prior to the facility inspection: · Annual fees due of $908 due on March 26, 2023. Both Executive Director and Administrator are aware. · Administrator Certificate up to date. · Emergency Disaster Plan (per H&S Code 1565) up to date. · Personnel Roster, Facility Sketch, LIC 500, LIC 610C and LIC 308 · Waivers and Exceptions: None at the moment. No deficiencies noted at this time. An exit interview was conducted with Jason Cunningham, Executive Director and Mehwish Khan, Administrator and a copy of this report was provided


summary: Facility Evaluation

raw_content:
Narrative:
On February 26, 2024, at approximately 09: AM, Licensing Program Analysts (LPAs) Farhaan Sarangi, Tatyana Shultz and Licensing Program Manager (LPM) Rosa Rodriguez arrived unannounced at Ennead THP/NMD administrative office which is located in a two-story building for the purpose of conducting an Annual/Required Inspection. LPA was greeted at the door by Executive Director, Jason Cunningham, and was granted access into the facility. LPAs and LPM along with the Executive Director toured the Administrative Office. LPAs and LPM observed the office to be clean and at a comfortable temperature with all exits free from obstruction. Upon entering the building there, is a receptionist area, to the right there is a staircase the leads to the second floor, the left side also has a staircase that also leads to the second floor, there are 4 exit doors, fire extinguishers are up to date. There are public restrooms in the building, and two conference rooms that can be used for private meetings. The suite has two desks with computers, locked file cabinet where private files will be kept, two sitting chairs and table. First Aid Kit was inspected and found to be appropriate at the time of the inspection. The building and suite are clean, safe, and sanitary. The conference room have a code to get into for privacy. The following documents were posted: License, Personal Rights, and Emergency Disaster Plan. Currently the facility has 5 placement's. Administrative office is within two hours of participants living areas, files are in a secure area, and has an area for private interviews or meetings. LPAs and LPM toured a client apartment and made observations (See LIC 812-Client Apartment Observation). The backyard was observed to have a shopping cart along with a rug (See LIC 9102-Technical Violation). LPAs and LPM also observed the window screen in 1 of 2 bedrooms had no window screen (See LIC 9102-Technical Violation). (Report continued on LIC 809C) LPAs and LPM reviewed two staff files and 5 client records. Executive Director and Administrator client files were reviewed, Criminal record clearances were verified. First Aid Certificate, Certified Administrators certificate valid and current, Job title/qualification verified, and Hours required training verified. Client Records consisted of needs and service plan with all the information required. Medical history and TILP were updated. During the inspection, two staff and one participant were interviewed. LPA requested the following documents to be sent: LIC 500- Personnel Report LIC 308- Designation of Responsibility LIC 309- Administrative Organization LIC 400- Affidavit regarding Client Cash Resources Most up-to-date Liability insurance Control of Property Register of Clients No deficiencies were cited at this time. An exit interview was conducted with Jason Cunningham, Executive Director and Mehwish Khan, Administrator and a copy of this report was signed and given to the Executive Director.

met_with: Program Administrator, Meswish Khan Executive Director, Jason Cunningham


summary: Facility Evaluation

raw_content:
Narrative:
On March 13, 2025 at approximately 9: AM, Licensing Program Analysts (LPAs) Zaria Turner and Tatyana Shulz, made an unannounced visit with the purpose of conducting an annual inspection to the above Transitional Housing Placement Program. LPAs Turner and Shulz met with Administrator, Meswish Khan, and a walk through of the interior and exterior was completed. LPAs conducted a walk though of the interior and exterior of the facility. The facility was clean, safe and kept free of obstruction. LPAs observed the posting of License, Personal Rights, and Emergency Disaster Plan. The facility consists a receptionist area, to the right there is a staircase the leads to the second floor, the left side also has a staircase that also leads to the second floor, there are 4 exit doors, fire extinguishers are up to date. There are public restrooms in the building, and two conference rooms that can be used for private meetings. The suite has two desks with computers, locked file cabinet where private files will be kept, two sitting chairs and table. First Aid Kit was inspected and found to be appropriate at the time of the inspection. The conference room has a code to get into for privacy. Currently the facility has 5 placement's. Administrative office is within two hours of participants living areas. Continue summary of inspection on 809-C The following domains were also reviewed during today's inspection, Physical Plant, Operation, Emergency Disaster Preparedness, and Staff and Client Records. A total of two staff files and 5 client files were reviewed. LPAs conducted two staff interviews. A review of the Licensing Information System indicates the facility is up to date on their facility annual fees. A deficiency was assessed during today's inspection. (See LIC 809-D) An exit interview was conducted with Meswish Khan, Administrator, and a copy of this report and the Appeal Rights were provided during today's inspection.

met_with: Meswish Khan, Facility Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On March 13, 2025 at approximately 9: AM, Licensing Program Analyst (LPAs) Zaria Turner and Tatyana Shulz, made an unannounced visit to the above Transitional Housing Placement Program. LPA Turner and LPA Shulz met with Executive Director, Jason Cunningham. LPA Turner and LPA Shulz arrived at approximately 9:30AM. LPAs were unable to contact the administrator due to the number on file being disconnected. LPAs left several voice mails and an email at approximately 10: AM. LPAs were able to contact Executive Director, Jason Cunningham at approximately 10: AM. The Executive Director stated they were unable to meet the LPAs at the office until after 11: AM. Facility Administrator, Meswish Khan contacted LPAs at approximately 11: AM and informed LPAs that they would be arriving in an hour and forty minutes. The Executive Director, Jason Cunningham arrived at the office and conducted a tour of the facility at 11: AM. The Executive Director was unable to assist LPAs in conducting the annual inspection and left the facility at 11: AM. The Executive Director contacted the Facility Administrator, and let LPAs know the Facility Administrator would be arriving at the facility at approximately 12: PM. LPAs Turner observed the following deficiencies: Mobile phone number on file is disconnected. Staff were not readily available until 12: PM when regular business hours are from 8AM to 5PM. (See LIC 809-D) An exit interview conducted and a copy of this report was left with Meswish Khan, Facility Administrator.

met_with: Executive Director, Jason Cunningham


raw_content:
Narrative:
Continuation from Based on the evidence gained, and statements in interviews the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations are being cited on the attached LIC9099D.

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

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

met_with: Administrator- Melody King


summary: Complaint Investigation - Unsubstantiated

raw_content:
Narrative:
photos and text messages during record review. The facility verified the maintenance worker is not directly employed by the facility, but the facility was aware of the maintenance workers derogatory comments and violation of confidentiality. Conflicting information was provided by facility staff regarding whether timely follow up was done with the Property Management company and maintenance worker. On 4/3/2024, Licensing Program Manager (LPM) Hillary Hall conducted an interview with facility Operations Manager Zach Anderson. Anderson indicated he had a conversation with the Property Management company regarding the inappropriate conduct of the maintenance worker, but could not recall the date of the conversation. Anderson indicated additional follow up will occur with the facility and Property Management company to ensure no further inappropriate conduct by maintenance staff occurs. Based on LPA's observations, interviews which were conducted, and records reviewed, although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove the violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED. A signed copy of this LIC-9099 report and the LIC-9099C were provided to the facility. An exit interview was conducted. Appeal rights were provided.

Investigation Findings:
13Licensing Program Analyst (LPA) Wendy Brown arrived unannounced at the facility on this date for the purpose of delivering findings for the complaint investigation, and met with Rayna Harkness, Office Manager. LPA Melinda Pope conducted the complaint investigation. LPA Pope opened the investigation with the facility on 1/30/24 and two staff were interviewed. During the course of the investigation, LPA Pope conducted additional interviews with two staff members, one THP participant, and one children's services social worker. LPA Pope reviewed records from the facility including: LIC 500, participant file and lease agreement, Notice to Enter, Day Contract, Serious Incident reports, and Copies of Text Messages and Photos. A THP participant gave permission for a maintenance worker contracted by the facility's Property Management company, to service their remote housing unit. The maintenance worker then took photos of the unit and texted derogatory comments about the participant to another participant. LPA Pope observed the UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Hillary Hall LICENSING EVALUATOR NAME: Wendy Brown 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 25-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHICO - RESIDENTIAL, COHASSET RD., STE. FACILITY NAME: ENVIRONMENTAL ALTERNATIVE THPP/THP+FC-SUSANVILLEFACILITY NUMBER: VISIT DATE: 04/03/2024

met_with: Rayna Harkness, Office Manager


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Hillary Hall conducted an unannounced annual inspection at the facility, located at Main St., Susanville, CA on 02/10/2022 at 9 am. LPA met with Rayna Harkness, Office Manager, who assisted with the inspection. Also present during the inspection were three social workers/case managers. LPA completed the inspection at 2:30pm. LPA completed the inspection using the CARE tool. LPA toured the facility and found the facility clean and safe for residents and visitors. LPA observed the license is posted in a prominent area. LPA observed the personal rights poster and complaints poster posted as required. LPA observed two restrooms available for staff, clients, and visitors, fully equipped with necessary supplies. LPA observed private space for conducting interviews, both upstairs and downstairs. The facility had fire extinguishers mounted that were last updated on 02/01/ LPA observed locking file cabinets for confidential client files. Staff files are kept electronically. The temperature in the facility was comfortable. LPA reviewed all six client files and interviewed two social workers. The third social worker was not available for an interview. LPA reviewed relevant information in staff files electronically. LPA did not observe any deficiencies during this inspection. Exit interview was conducted with the Office Manager. A signed copy of this LIC-809 and LIC-9102AN were provided to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Lyta Vue arrived unannounced at the facility on 1/17/24 at 9: AM. LPA rang the doorbell and no one was there. LPA made a call to the phone number but no one picked up. LPA called the EA-Quincy and was told the staff who was on duty was at a training. LPA will attempt at a later date.


summary: Facility Evaluation

raw_content:
Narrative:
On 1/18/24, Licensing Program Analyst (LPA) Lyta Vue arrived unannounced at the facility and met with Rayna Harkness, Office Manager. The purpose of the visit was to conduct a Required Annual Inspection of the facility. The last Annual inspection for the facility was on 2/10/22. LPA utilized the CARE Tool to complete the Annual inspection. LPA conducted an inspection of the physical plant and checked for all necessary requirements. The facility was clean and organized and maintained an acceptable room temperature. The facility has 2 offices for social workers and 1 confidential interview/visitation room. LPA observed the proper postings including facility license, complaint hotline, and emergency disaster plan. The restrooms for clients and staff were clean. Smoke alarms and carbon monoxide detectors were in working order, the 2 fire extinguishers were current up to July 2024, and a first aid kit was fully stocked. Evacuation drills for the facility were completed quarterly. LPA observed client files stored in a locked filing cabinet in the Office Manager's office and electronically with password. The facility has no outstanding fees. The facility has four (4) Non-Minor Dependent clients. Clients live in remote site apartments. No client resides more than two hours from the facility. The facility employs Social Worker, Supervisor, and Office Manager. LPA reviewed 3 personnel staff files. All three staff had completed criminal record clearances and both the Social Worker, and the Social Worker Supervisor met minimum education experience qualifications. All First Aid and CPR certifications were up to date for all staff personnel. LPA interviewed 1 staff personnel. Staff personnel indicated Social Worker does not have more than THP clients on their caseload. LPA reviewed four client files. All clients had signed Admission Agreements. Client files had current Needs and Service Plans, signed by the client and placing agency. Needs and Services Plan detailed adequate supportive services the facility offers to the clients. Report continued on 812c No citations were given on this date. A signed copy of this LIC-809 (and LIC-809C) report was provided to Rayna Harkness, Office Manager. An exit interview was conducted. End of report.


summary: Facility Evaluation

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Narrative:
On 02/12/26, Licensing Program Analysts (LPAs) Lyta Vue and Misty Valencia arrived unannounced at the facility and met with Rayna Harkness, Office Manager and Gina Dwyer, Supervisor. The purpose of the visit was to conduct a Required Bi-Annual Inspection of the facility. The last Annual inspection for the facility was on 01/18/24. LPA utilized the CARE Tool to complete the Annual inspection. LPA conducted an inspection of the physical plant and checked for all necessary requirements. The facility was clean and organized and maintained an acceptable room temperature. The facility has 2 offices for social workers and 1 confidential interview/visitation room. LPA observed the proper postings including facility license, complaint hotline, and emergency disaster plan. Accreditation will expire on 08/31/27. The restrooms for clients and staff were clean. Smoke alarms and carbon monoxide detectors were in working order, the 2 fire extinguishers were current up to July 2026, and a first aid kit was fully stocked. Evacuation drills for the facility were completed quarterly. LPA observed client files stored in a locked filing cabinet in the Office Manager's office and electronically with password. The facility has no outstanding fees. The facility has five (5) Non-Minor Dependent clients. Clients live in either remote-site apartments or houses. No client resides more than two hours from the facility. The facility employs one (1) Social Worker and one (1) Social Worker Supervisor. Annual Report continued on 809c LPA reviewed one (1) Social Worker and one (1) Social Worker Supervisor personnel files. Social work personnel had completed criminal record clearances and met minimum education and experience qualifications. All First Aid and CPR certifications were up to date for Social Worker personnel. LPA interviewed two (2) social worker personnel. Social work personnel indicated they did not have more than 12 clients on their caseload. LPA reviewed five (5) client files. All clients had signed Admission Agreements. Client files had current Needs and Service Plans, signed by the client and placing agency. Needs and Services Plan detailed adequate supportive services the facility offers to the clients. No citations were given on this date. A signed copy of this LIC-809 report was provided to the Office Manager. An exit interview was conducted.


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Narrative:
Discussions between C1 and RP were about multiple sexual partners, attraction(s) between C1 and RP, "love being expansive and impossible to compartmentalize", being "fluid and undefinable at times", and C1 or RP having emotionally involved communications between them. One of the messages uncovered stated "we have a connection & we care about each other". The allegation that RP engaged in conduct that is inimical to the health, morals, welfare, or safety of clients in the facility is related to this inappropriate contact, conversations and communications between C1 and RP. In addition, Investigator Burton received information that C1 and RP were found by a third party sleeping clothed together in the same bed at least one time and a picture showing that C1 and RP in clothes and in bed together (not the same incidents). RP was told that C1 may have had a crush on RP but RP did not stop the inappropriate messages or communications and even admitted that communications between C1 and RP were emotionally involved. As a result of the interviews conducted, documentation reviewed and investigation conducted, the allegation that resource parent had an inappropriate relationship with client in care and resource parent engaged in conduct that is inimical to the health, morals, welfare, or safety of clients in the facility are SUBSTANTIATED at this time meaning that the allegation is valid because the preponderance of the evidence standard has been met. Facility cited for violation of California Code of Regulations, Title Division Six, regulation 84072(d) Personal Rights. Investigation shows that RP carried on an inappropriate relationship with C1 that appeared to be emotionally abusive in nature. These discussions included content of a sexual nature and were inappropriate as the nature of the relationship was that of care provider/mentor and youth in care. Facility cited for violation of Health and Safety §1569.58(a)(2) Officers, directors and employees of licensed facility... Investigation shows that staff engaged in conduct that is inimical to the health, morals, welfare or safety of an individual in or receiving services from the facility, or the people of the State of California as it relates to the inappropriate contact, conversations and communications between C1 and RP. Exit interview conducted with Kitty Cannon and document provided. When interviewed, C1 alleged that the relationship between C1 and RP was "intimate and very sexual" but denied there was sexual intercourse or penetration or other contact of a sexual nature. C1 denied that C1 and RP ever kissed but did make statements about inappropriate touching over the clothing that could not be corroborated. As a result of the interviews conducted, documentation reviewed and investigation conducted, the allegation that resource parent had an inappropriate sexual relationship with a client in care is UNSUBSTANTIATED at this time meaning that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted and documentation was provided to Kitty Cannon.

Investigation Findings:
13Licensing Program Analyst (LPA) Danielle Walker-Flores made an unannounced complaint inspection on 12/30/21 and met with Kitty Cannon, Office Manager to discuss the findings of the complaint allegations. LPA informed Kitty Cannon that the complaint investigation included an initial inspection of the facility on 9/23/2021 by LPA Walker-Flores. However, files were unable to be reviewed due to a lack of documentation provided by the agency. Investigator Shannan Borton, Investigations Branch, conducted this complaint investigation. A review of documentation provided by another facility for resource parent, (RP, see confidential names list titled 12/30/21) was conducted. This resource parent was employed at a group home where they were introduced to the client. Interviews were conducted for current staff and clients, and other individuals relevant to the investigation from 8/6/21 through 10/21/21. LPA informed Kitty Cannon that the allegation that RP had an inappropriate relationship with a client in care is related to the relationship between C1 and RP. Investigation shows that RP and their partner allowed C1 to move into their home through an independent living arrangement overseen by this agency. While C1 was in the home, investigation showed that there was inappropriate contact and conversations between C1 and RP as demonstrated by text messages and photos obtained by the investigator. Continued on 9099C SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Daniel Allmon LICENSING EVALUATOR NAME: Danielle Walker LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, FACILITY NAME: ENVIRONMENTAL ALTERNATIVES-GRASS VALLEYTHPP/THP+FCFACILITY NUMBER: VISIT DATE: 12/30/2021

met_with: Kitty Cannon - Office Manager


narrative: Continuation from Based on the evidence gained, and statements in interviews the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations are being cited on the attached LIC9099D.

investigation_findings: UnsubstantiatedEstimated Days of Completion: Estimated Days of Completion: Estimated Days of Completion:

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:


summary: Facility Evaluation

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Narrative:
Licensing Program Analysts (LPAs) Robyn Word and Tina Thorn made an unannounced annual inspection on 4/26/2023 at 9: AM and met with Katelyn Pomeroy- Social Worker and Administrator Melody King and toured the agency inside and out. The THP+FC is in a shopping plaza. The THP+FC shares an office with the Foster Family Agency and CalAim. THP+FC files/records are in the front office and kept in locked file cabinet. License is posted for Transitional Housing Placement Program. LPA observed that the disaster plan is posted as required. Bathroom facilities are available for client and visitor use and appeared to be clean and sanitary as required. LPA observed office space for private interviews as necessary. LPA observed the temperature of the office space to be comfortable. Fire extinguisher is mounted and tagged as inspected on July 25, 2022. THP+FC is licensed to serve 62 clients, ages 18-21. Clients are housed throughout different counties. There are currently 6 clients in the THP+FC program and 1 staff/ Case Worker assigned to the 6 placements. The office area is clean. The LPAs did observe water damage on the ceiling area. The Administrator stated that a maintenance request was sent to the building manager on 4/10/23. LPA's requested proof of follow-up with Property Manager within 30 days. LPA reviewed 3 of the 6 client files, and staff files including the Case Worker file and the Administrator file. Staff and client files are secured. The copy of license is posted. A review of records indicate staff have criminal record and child abuse clearance. CPR and First Aid certification and training hours are complete. There are no title 22 deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility


summary: Facility Evaluation - 1 deficiency

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Narrative:
On 05/22/2025, Licensing Program Analyst (LPA) Yesenia Vallejo, and LPA Aleza Ruiz arrived unannounced at the facility and met with Abby Hoekstra, Office Manager. The purpose of this visit was to conduct a required Bi-Annual Inspection of the facility. The last Bi-Annual inspection for the facility was on 04/26/2023. LPA utilized the CARE Tool to complete the inspection. LPA conducted an inspection of the physical plant and checked for all necessary requirements. The facility was clean and organized and maintained an acceptable room temperature. The facility has three offices for social workers/case managers and two confidential interview/visitation rooms on the second floor. LPA observed the proper postings including, facility license, complaint hotline, and emergency disaster plan. The restrooms for clients and staff were clean. Fire extinguishers were current, and a first aid kit was fully stocked. Evacuation drills for the facility were completed quarterly. LPA observed client files were stored electronically with password protection. The facility has no outstanding fees. The facility has three Non-Minor Dependent clients. Clients live in either host homes or remote site apartments. No client resides more than two hours from the facility. The facility employs one Case Manager, and one Supervisor/Program Manager. LPA reviewed one Case manager personnel files, and one Supervisor/Program Manager files. Both personnel had completed criminal record clearances and met minimum education and experience qualifications. All First Aid and CPR certifications were up to date for each personnel. LPA was unable to interview Case Manger as they're out on leave. LPA was unable to interview Supervisor/Program Manager due to being out of office during time of inspection. LPA will conduct a phone interview. LPA reviewed three client files. All clients had signed Admission Agreements. Client files had current Needs and Service Plans, signed by the client and placing agency. Needs and Services Plan detailed adequate supportive services the facility offers to the clients. Facility is issued two citations per CCR 86065(f)(4) and 86064(h). A signed copy of this LIC-809, LIC-809C and LIC809D report was provided to Abby Hoekstra, Office Manager. An exit interview was conducted. Appeal Rights were provided.

Deficiencies:
86064(h): (h) The administrator shall complete training related to the sexual and reproductive rights of children in foster care that includes the following topics

met_with: Abby Hoekstra- Office Manager


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Narrative:
In LPA's review of the Premise Report, collected from the Sacramento Sheriff's Department, it lists out all Calls for Service made by members of the public, at or tied to the apartment complex address, from January 2020 through Present 2023. There were 280 total calls for service, some of which were four for shots fired, two assault, one sexual assault, 15 battery, six assault with a deadly weapon, 90 disturbances, four threats with a gun or other weapon, three threats, five burglary, one petty theft, one grand theft, one auto theft, three vandalism, four trespassing, two suspicious vehicles, and eight suspicious circumstances. These records only show what kind of call was made, not where the violation occurred, so it is possible not all of these events occurred at the apartment complex, however were reported by individuals at the complex, or about individuals at the complex. In LPA's review of the Case Notes provided, LPA found instances where maintenance was needed for minor issues, such as the heater pilot being out and a broken closet door, and the EA Case Manager (CM) assisted the client in getting those problems fixed. There were no concerns reported about insect issues. In Case Notes from 2020, when the client was first placed in November 2020, the client was not happy with the apartment due to safety concerns about personal conflicts with individuals in the community, and requested a change. EA then moved the client to the apartments the client then resided in from December 2020 to February 2023, to ensure the client felt safe. More current Case Notes from 2023 also detail how CM was helping the client get what they needed in regard to school, employment, and certifications. There were many entries which detailed all of CM's efforts in working with the client on getting the client an apartment they wanted, and supporting the client through their decisions. In several case notes it shows that CM was working on getting the client into another apartment of their choosing in 2023, however the client was indecisive about where the client actually wanted to live, whether it be with EA, a SILP, or with their spouse. The apartment the client was thinking about choosing was also out of EA's reasonable price range. The client went ahead with moving plans without speaking to, or working with EA at times, which led C1 to voluntarily leaving EA. Most recently, on 4/23/2023, the client submitted an inquiry about coming back to EA. LPA also observed the environment of the apartments. LPA did observe a bullet hole in the hallway of one of the buildings, pointed out to LPA by a tenant. This tenant stated that had been there since before the tenant lived there, which is over four years ago. LPA also observed one bullet hole in the face of the building to the right of the vending machines, and a bullet mark on the vending machine cage itself. It is unclear when those marks were made. LPA observed many children out and playing together, as well as several adults going about their business. LPA observed all individuals to appear homed, and non-suspicious. LPA did not observe any criminal activity while she was at the apartment complex. When LPA conducted interviews with the six randomly selected tenants, LPA could observe the apartments, to varying degrees whether LPA went inside or not, and observed all spaces to be modernized, and in good condition. LPA did not observe any bugs or other pests. When LPA did a walk-through of the apartment unit related to this complaint specifically, LPA also observed it to be clean, semi-modernized, and without bugs or other pests. Confidential interviews conducted revealed the following: In LPA's interviews with the Intake Workers, Director, Case Manager, and Social Work Supervisor, it was confirmed that it is the client's choice to accept an apartment, and if they do not approve of it, EA will work to find a better match for the client. During LPA's interview with the Case Manager, he stated he never observed any insects. LPA Burgess and LPA Monica Roberts requested in total three times, the photographic evidence from the individual involved, of the insects which were alleged to have been in the apartment, however LPA never received them. In LPA's interview with the Property Manager (PM), there were no records of insects being reported as an issue in the client's unit, however, the PM also stated that they will do regular preventative insect spraying. All six randomly-selected tenants, and the one current EA client, that LPA interviewed stated they felt safe at the apartment, and some reported small issue with children running around with trash, or the homeless coming into the complex. PM also stated that all issues that were reported to her by the client were addressed by maintenance. PM stated that the area is a rough area, but has improved since she has come to the complex in May of 2021, and they have gotten new tenants. In LPA's interview with the Deputy, it was confirmed that the area is a, "dangerous," area with drugs, gangs, homelessness, poverty, and struggles; however, many areas of Sacramento are like that, and at the same time, you will see children walking home from school, and regular non-criminal daily life. Additionally, the Deputy explained that the clients are adults and can choose whether or not to live there. LPA was also made aware in this interview that bullet holes/shootings happen in all areas of Sacramento, not only apartments such as this one. Based on all information collected and interviews conducted, LPA found that the area the apartment is in does have crime and dangers, however that is common in other areas as well. LPA learned that tenants feel safe, and Property Management addresses concerns. LPA found that EA Case Manager worked to support and assist the client in meeting their needs and helping them to get what they want as well. LPA also found that the clients have the final say-so in where they will be placed and can reject a placement, as well as EA will move them if they feel unsafe. LPA was informed there were cockroaches in the apartment by one individual, however saw no evidence of this, and did not receive evidence to prove such. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with SWS and a copy of this report and appeal rights was left with her.

Investigation Findings:
13Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced complaint investigation inspection at the agency and met with Social Work Supervisor (SWS), who assisted with the inspection. LPA investigated this complaint by observing the apartment's environment, reviewing Case Notes, Lease Agreement, Police Premise Reports, Emails, and by conducting confidential interviews with the Reporting Party, a current client, six randomly selected tenants in the apartment complex, the Property Manager, a Deputy from the Sacramento Sheriff's Department, the Social Work Supervisor, THPP Director, Case Manager, and two Intake Workers on 3/16/2023, 4/3/2023, 4/5/2023, 4/10/2023, 4/11/2023, 4/17/2023, 4/25/2023, 4/26/2023, and 4/27/2023. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Alyssa M Burgess LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, NATOMAS PARK DR., STE FACILITY NAME: ENVIRONMENTAL ALTERNATIVES-SAC THPP/THP+FCFACILITY NUMBER: VISIT DATE: 05/05/2023

met_with: Jamie Cobabe


raw_content:
Narrative:
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. A copy of this report and appeal rights was left with the facility. End of report.

Investigation Findings:
13On 5/26/203, at 10:25 a.m., Licensing Program Analyst (LPA) Monica Roberts conducted an unannounced inspection at this agnecy to close this complaint investigation and deliver the findings. LPA was met by Kathleen Cannon, Office Manager, with whom the report was discussed. LPA discussed the information collected that helped form this decision. On 4/26/2023, LPA Roberts collected the needs and services plan, client face sheet, client P&I ledger and a copy of the house agreement from the agency. Interviews were conducted with the following: Agency Social Workers on 5/12/2023, County Social Worker on 5/15/2023, and Child 1 (C1) and her neighbors on 5/19/2023. (See LIC811s for details). Although C1 stated that she tried to pick up her money at the agency, there is an agreed upon time to receive her money and she admits that she is not showing up at that time. Agency states that they are not always available to dispense money and therefore that is why they have the system in place that they do, however per the signed agreement, they follow through. C1 agrees with this. (Continued on LIC 9099-C) UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Jodean Greene LICENSING EVALUATOR NAME: Monica Roberts LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 23-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NO. Cal Cr/res., Natomas Park Dr., STE FACILITY NAME: ENVIRONMENTAL ALTERNATIVES-SAC THPP/THP+FCFACILITY NUMBER: VISIT DATE: 05/26/2023


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an announced Prelicensing Inspection at the agency and met with THP Director (TD) Jenna Bethancourt, who assisted with the inspection. The agency is relocating from their Woodland THPP Office. The office is located in an office building. The THPP will continue to serve up to 150 participants. Once licensed, the agency will convert licensed information over to current placements. TD confirmed knowledge that all units must be within a 2-hour drive from this office. The program plans to utilize remote sites and host-homes. LPA, TD, and Office Manager Asifa Ali conducted a walk-through of the agency. LPA observed a lobby, and a side office area, three visits rooms, two kitchens, four bathrooms, two conference rooms, one file room, one lounge, five office work spaces, two storage garages/warehouses, and one storage closet. LPA observed all spaces to be clean, free of hazards, and equipped adequately with all needed supplies. LPA observed there to be multiple carbon monoxide detectors and smoke detectors, and three fire extinguishers which are up to date. LPA observed the file cabinets to be locked, which is where the agency will store client and staff records. LPA observed five first aid kits in the office. All sharps, and chemicals/cleaning solutions are locked. LPA observed posted childrens' rights, the complaint/grievance policy and forms posted. LPA observed no deficiencies. The agency has submitted all required documents for the relocation. The agency is ready for licensure, dated 3/23/2022. An exit interview was conducted with TD and a copy of this report was emailed to her with a read receipt, which will serve as the record of receipt.

met_with: Jenna Bethancourt


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Alyssa Burgess made an unannounced Post Licensing Inspection at the agency and met with Agency Social Worker Supervisor (SWS) Jamie Cobabe, who assisted with the inspection. LPA and SWS conducted a walk-through of the facility and LPA observed: two conference rooms, one file room, seven office spaces, two storage areas, one pantry, two kitchens, three visitation rooms, a staff lounge, the lobby, and four bathrooms. LPA observed no deficiencies. All fire extinguishers were in date and charged. All client files were locked. All areas of the building were clean, in good repair, and had no obstructions in the walkways. There are working smoke detectors. LPA reviewed five staff files and five client files. LPA found that 8 of 15 staff who work at this THPP license are not associated to the license. However, all 15 are DOJ/FBI/CACI cleared and associated to the agency's Sacramento FFA license. LPA found that all other staff requirements were met. For client files LPA found that the Administrator does not sign the Needs and Services Plans as required. One out of five NSPs were out of date, and the one that was out of date, was being drafted. All other requirements for client files were met. LPA interviewed two Social Workers, one Case Manager, and one Social Work Supervisor. On this date the agency is being cited for violations of the California Code of Regulations, Title 22, Section 86019(e)(2) and Health and Safety Code (HSC) 1565(a)(7). An exit interview was conducted with SWS and a copy of this report, appeal rights, and confidential names list was left with her.