facility_name: JOURNEY OF HOPE XXI INC

summary: Facility Evaluation

raw_content:
Narrative:
On August 15, Licensing Program Analyst (LPA) Jean Stidman conducted an announced pre-licensing facility inspection and met with Adebola Sanyaolu, Facility Administrator, and Abiodun Sanyaolu, House Manager. LPA, Administrator and House Manager conducted a joint inspection of the inside and outside of the facility. The group home is requesting to be licensed for a capacity of 4 ambulatory clients, ages seven to 17 years old. There were no clients in care at the time of the inspection. Clients with Special Health Care Needs (SHCN) will not be admitted. The home is a single-story home with two double occupancy bedrooms and one bathroom for the clients and one bedroom and bathroom for the House Manager. The facility backyard has a deck off the sliding glass door and is enclosed with a fence. The front yard is free of clutter; and the passageways and egress were unobstructed. The backyard fence along the right side of the house has bent/broken boards and is leaning over. The right side of the house has debris that needs to be removed and the fence needs to be repaired prior to being licensed. The backyard is missing toy/activity equipment and seating for clients. LPA observed a working Carbon Monoxide detector in the hallway and working smoke alarms in each bedroom, and the living area. LPA observed that there was a fire extinguisher in the kitchen that was charged in February 2022. The house was clean, safe, sanitary and in good repair. LPA observed the facility has at least a 7-day supply of non-perishable food, a 3-day supply of perishable food and the freezer was stocked with frozen foods. LPA observed that there were ample dishes, cups, utensils, and items used for cooking meals in the kitchen. Sharp knives are to be kept in a locked cabinet in the kitchen. Cleaning supplies and chemicals are to be stored under the kitchen sink ina locked cabinet. Menus and meal schedules were posted in the kitchen. LPA observed that the medications, multiple first aid kits are stored in a locked cabinet in the kitchen. The client and staff files are kept locked in a file cabinet in the dining room. This client and extra hygiene products are kept locked in the hall cabinet. LPA observed that there was a laundry area, including a washer and dryer, in the garage. LPA observed the hall closets have stored life vests, extra bedding, comforters, extra towels and wash cloths. The home has an Emergency Disaster Plan, Client Personal Rights and floorplan are posted in the entrance hallway and the floorplans are posted in each client bedroom. The Grievance policy is posted in the living room and the calendar of activities is posted in the kitchen. LPA observed that the bedrooms have two single beds with a mattress cover and pad, fitted sheet, top sheet and blanket and bedspread, a drawer for each client's personal items, night stand, lamp, and ample closet area. The living room consisted of two couches, a desk, a television and game system. The facility has a working landline phone located in the living room. LPA also observed activity supplies in the living room of board games and video games for the clients. There was one bathroom in the hall for the clients that is equipped with a shower/tub combination and a shower curtain for privacy. The bathroom has a working toilet, shower, and sink faucet and has soap and paper towels for hand washing. The second bathroom was located at the House Manager's bedroom and is not for clients. The water temperature was measured to be at 90.5 degrees Fahrenheit the water temperature was turned up during the inspection Facility will adjust the water temperature until it reaches between 105-120 degrees Fahrenheit. LPA observed that the dining area was off of the kitchen and the table was set up for placement of four and contained four chairs along with two barstools at the kitchen counter. An exit interview was conducted with Adebola Sanyaolu, Facility Administrator, and Abiodun Sanyaolu, House Manager a copy of this report was left with Adebola Sanyaolu, Facility Administrator, and Abiodun Sanyaolu, House Manager.

met_with: Adebola and Abiodun Sanyaolu


state: CA

summary: Facility Evaluation

raw_content:
Narrative:
On August 22, Licensing Program Analyst (LPA) Jean Stidman conducted an announced pre-licensing facility inspection and met with Adebola Sanyaolu, Facility Administrator, and Abiodun Sanyaolu, House Manager. LPA, Administrator and House Manager conducted a joint inspection of the of the facility to inspect technical violation corrections. The group home is requesting to be licensed for a capacity of 4 ambulatory clients, ages seven to 17 years old. There were no clients in care at the time of the inspection. Clients with Special Health Care Needs (SHCN) will not be admitted. The backyard fence on both sides of the house has been repaired, the debris in the backyard along the right side of the house has been removed, the hot water temperature is 109 degrees Fahrenheit. The facility has supplies, equipment and reading material necessary to implement the planned indoor and outdoor activities and has an outdoor seating area for the clients. Facility cited violation of California Health and Safety Code 1565(a)(7)(A) and 1565(a)(7)(E) technical violations. The facility will have 30 days from the date of the inspection on 8/22/22 to complete the corrections. An exit interview was conducted with Adebola Sanyaolu, Facility Administrator, and Abiodun Sanyaolu, House Manager a copy of this report was left with Adebola Sanyaolu, Facility Administrator, and Abiodun Sanyaolu, House Manager. The facility is granted it's provisional license effective 8/22/2022.

report_type: Facility Evaluation

visit_type: Prelicensing


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Jean Stidman made an unannounced Post Licensing inspection on 6/26/23 at 12:00pm. During the inspection LPA met with Abiodun Sanyaolu House Manager who assisted with the inspection. LPA conducted a walk-through of the facility inside and out. Facility staff-client ratio at time of inspection is one staff/no kids present, Number of staff interviewed _2_ Number of clients interviewed N/A. LPA observed # _3_bedrooms, # _2_bathrooms. LPA observed the sliding glass door was replaced during the inspection. LPA inspected and/or reviewed the following: Physical Plant Posting of license_X_ Personal Rights_X_ Disinfectants/Cleaning solutions inaccessible_X_ Refrigerator Temperature at or below 45 degrees F _39 degrees_ Freezer Temperature at or below 0 degrees_-9 degrees Nonperishable Foods one week and fresh perishable foods two days minimum_X_ Menu present and posted__X_ Working telephone _X_Carbon monoxide detector_X_ Smoke Detector _X_ First Aid Kit fully stocked_X__ Common Room available__X_ Dining area (enough seating, furniture good condition, not broke or damaged) _X_ Medication centrally stored, locked/inaccessible N/A Office (locked and privacy) N/A Hot Water between 105-120 degree F (Properly labeled if over 125 degree F)_107 degrees Fire Extinguisher (note inspection date) charged February 2023_ Toilets wash basin, bath and shower fixtures in good repair/no leaks/hot water temperature _X_ Soap and Paper towels __X_ Laundry Facilities(available)_X_ Bedrooms-required linen and furnishings _X__Motor Vehicle properly maintained, lights, tires, registration/insurance and working seat belts_N/A_ Facility free of vermin _X_ Operations Complaint Procedures For Youth Reviewed _x_ Board Minutes Reviewed_X_ Disaster Preparedness Fire Drills conducted and documented X Disaster preparedness supplies verified _X Emergency Intervention Review of manual restraint log N/A Staff training _X_ Staffing/Volunteers Number of Staff files reviewed _3__Criminal record clearances verified 3___ First Aid Certificate__3_ Certified Administrators certificate valid and current__X_ Job title/qualification verified _X_ Hours required training verified _N/A_as the facility does not have any paid staff. Client Records Number of Clients files reviewed N/A (the facility does not have any clients) The following items were reviewed for compliance in the regional office prior to the facility inspection: Annual fees, Administrator Certificate for: Adebola Sanyaolu, Emergency Disaster Plan (per H&S Code 1565), LIC500, LIC610C and LIC308. An exit interview was conducted and a copy of this report was left with Abiodun Sanyaolu House Manager.

visit_type: Annual

met_with: Abiodun Sanyaolu House Manager


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Jean Stidman made an unannounced Annual inspection on 8/14/23 at 11:45am. During the inspection LPA met with Adeobla Sanyaolu, Administrator, who assisted with the inspection. LPA conducted a walk-through of the facility inside and out. Facility staff-client ratio at time of inspection is one staff/no kids present, Number of staff interviewed _2_ Number of clients interviewed N/A. LPA observed # _3_bedrooms, # _2_bathrooms. LPA inspected and/or reviewed the following: Physical Plant Posting of license_ok_ Personal Rights_ok_ Disinfectants/Cleaning solutions inaccessible_ok_ Refrigerator Temperature at or below 45 degrees F _39 degrees_ Freezer Temperature at or below 0 degrees_-5 degrees Nonperishable Foods one week and fresh perishable foods two days minimum_ok_ Menu present and posted__ok_ Working telephone _ok_Carbon monoxide detector_ok_ Smoke Detector ok First Aid Kit fully stocked_ok__ Common Room available_ok_ Dining area (enough seating, furniture good condition, not broke or damaged) _ok Medication centrally stored, locked/inaccessible N/A Office (locked and privacy) N/A Hot Water between 105-120 degree F (Properly labeled if over 125 degree F)_105 degrees Fire Extinguisher (note inspection date) charged February 2023_ Toilets wash basin, bath and shower fixtures in good repair/no leaks/hot water temperature _ok_ Soap and Paper towels ok_ Laundry Facilities(available)_ok_ Bedrooms-required linen and furnishings _ok_Motor Vehicle properly maintained, lights, tires, registration/insurance and working seat belts_N/A_ Facility free of vermin _ok_ Operations Complaint Procedures For Youth Reviewed _ok_ Board Minutes Reviewed_ok_ Disaster Preparedness Fire Drills conducted and documented ok Disaster preparedness supplies verified ok Emergency Intervention Review of manual restraint log N/A Staff training _ok_ Staffing/Volunteers Number of Staff files reviewed _3__Criminal record clearances verified 3___ First Aid Certificate__3_ Certified Administrators certificate valid and current__ok_ Job title/qualification verified _ok_ Hours required training verified _N/A_as the facility does not have any paid staff. Client Records Number of Clients files reviewed N/A (the facility does not have any clients) The following items were reviewed for compliance in the regional office prior to the facility inspection: Annual fees, Administrator Certificate for: Adebola Sanyaolu, Emergency Disaster Plan (per H&S Code 1565), LIC500, LIC610C and LIC308. An exit interview was conducted and a copy of this report was left with Adeobla Sanyaolu, Administrator.

met_with: Adeobla Sanyaolu, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 8/14/ Licensing Program Analyst (LPA) Jean Stidman met with Adeobla Sanyaolu, Administrator (AD), and Abiodun Sanyaolu, House Manager (HM), for the purpose of providing technical assistance for the facility's program statement and plan of operation. LPA, AD and HM reviewed the revisions submitted in May 2023 and discussed the revisions still needed. LPA, AD and HM also reviewed Title 22 regulations as needed for the necessary revisions. LPA provided a copy to AD and HM of the revisions needed.

visit_type: Case Management


summary: Facility Evaluation

raw_content:
Narrative:
On 8/7/ Licensing Program Analysts (LPAs) Jean Stidman and Elena Gonzalez-Soto conducted an Annual Inspection. LPAs inspected the facility inside and outside. When LPAs arrived there was one staff and three clients present then during the inspection the Administrator arrived. During the inspection LPA met with Adebola Sanyaolu, Administrator who assisted with the inspection. LPA conducted a walk-through of the facility. Number of staff interviewed two Number of clients interviewed zero LPA observed # 3 bedrooms, #23 bathrooms LPAs inspected and/or reviewed the following: Physical Plant Posting of license_X_ Personal Rights__X___ Disinfectants/Cleaning solutions inaccessible__X___ Refrigerator Temperature at or below 45 degrees F 27 degrees Freezer Temperature at or below 0 degrees_0 degrees F Nonperishable Foods one week and fresh perishable foods two days minimum__X___ Menu present and posted__X__ Working telephone __X_ Carbon monoxide detectors __X_Smoke Detector _X__ First Aid Kit fully stocked_X__ Common Room available__X__ Dining area (enough seating, furniture good condition, not broke or damaged) __X_ Medication centrally stored, locked/inaccessible _X_ Hot Water between 105-120 degree F (Properly labeled if over 125 degree F__110 degrees_ Fire Extinguishers inspected July 2024. Toilets wash basin, bath and shower fixtures in good repair/no leaks/hot water temperature _x Soap and Paper towels __X_ Laundry Facilities(available) __X___ Bedrooms-required linen and furnishings __X___ Motor Vehicle properly maintained, lights, tires, registration/insurance and working seat belts_X__ Facility free of vermin _X__ Bedroom (required bedding/furniture, furniture in good repair) __X_Operations Complaint Procedures For Youth Posted _X__ Board Minutes Reviewed __X_Disaster Preparedness Disaster and mass casualty plan updated and available __X__ Quarterly Drills conducted and documented__x__ Disaster preparedness supplies verified __X___Emergency Intervention Review of manual restraint log _X_ Staff training _X__Staffing/Volunteers Number of Staff files reviewed _three Criminal record clearances verified_three_First Aid Certificate__three Certified Administrators certificate valid and current__X_ Client Records Number of Clients files reviewed_three Individual Progam Plan_three Centrally Stored Medication and log reviewed _three Psychotropic Medication and log reviewed _three Cash Resources__three The following items were reviewed for compliance: Annual fees, Administrator Certificate, Annual Emergency Intervention Log, LIC500 and LIC610C. Exit interview conducted and a copy of this report was left with Adebola Sanyaolu, Administrator.

met_with: Adebola Sanyaolu, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Jean Stidman made an unannounced Annual inspection at 9:15am. During the inspection LPA met with Adebola Sanyaolu, Administrator, who assisted with the inspection. LPA conducted a walk-through of the facility. There was one staff present and no children at the beginning of the inspection. Three other staff arrived during the inspection. Number of staff interviewed _two Number of clients interviewed _one LPA observed # 2 children's bedrooms and 1 children's bathroom and one staff bedroom and bathroom. LPA inspected and/or reviewed the following: Physical Plant Posting of license_X_ Personal Rights__X___ Disinfectants/Cleaning solutions inaccessible__X_Refrigerator Temperature at or below 45 degrees F 43 degrees Freezer Temperature at or below 0 degrees_0 degrees F Nonperishable Foods one week and fresh perishable foods two days minimum__No___ Menu present and posted__X__ Working telephone __X_ Carbon monoxide detectors __X_Smoke Detector _X__ First Aid Kit fully stocked_X__ Common Room available__X__ Dining area (enough seating, furniture good condition, not broke or damaged) __X_ Medication centrally stored, locked/inaccessible _X_ Hot Water between 105-120 degree F (Properly labeled if over 125 degree F__119 degrees_ Fire Extinguishers inspected Feb 2025. Toilets wash basin, bath and shower fixtures in good repair/no leaks/hot water temperature _x Soap and Paper towels __X_ Laundry Facilities(available) __X__ Bedrooms-required linen and furnishings __X___ Motor Vehicle properly maintained, lights, tires, registration/insurance and working seat belts_X__ Facility free of vermin _X__ Bedroom (required bedding/furniture, furniture in good repair) __X___ No Video Cameras were observed in the facility. Operations Complaint Procedures For Youth Posted _X__ Board Minutes Reviewed __X__Disaster Preparedness Disaster and mass casualty plan updated and available __X__ Quarterly Drills conducted and documented__x__ Disaster preparedness supplies verified __X___Emergency Intervention Review of manual restraint log _No Restraints were observed_ Staff training _X___Staffing/Volunteers Number of Staff files reviewed _five Criminal record clearances verified _five_ First Aid Certificate__five__ Certified Administrators certificate valid and current__X_ Client Records Number of Clients files reviewed five Individual Program Plan five Centrally Stored Medication and log reviewed three Psychotropic Medication and log reviewed three__Cash Resources_four The following items were reviewed for compliance: Annual fees, Administrator Certificate for: Adebola Sanyaolu, Administrator, Emergency Intervention Log, LIC500 and LIC610C. The facility is cited violation of California Code of Regulations, Title 22, Division 6, regulation 80026(h)(1)(A)(h) Safeguards for Cash Resources, Personal Property, and Valuables of Residents and 80069(a) Client Medical Assessment. An exit interview was conducted and a copy of this report was left with Adebola Sanyaolu, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On 6/6/ Licensing Program Analyst (LPA) Jean Stidman conducted an unannounced inspection. At the time of LPA's arrival there were no children in placement and only one adult who resides in the home was at the facility. LPA observed the sliding glass door handle frame comes off the glass door, the lawn is full of weeds/grass that is approximately two feet tall and the home is cluttered with items on the dining room table, living room table and TV stand and electrical cords are accessible under the glass desk in the living room. LPA observed the clutter in the living room and kitchen table were cleaned up and the lawns were mowed during the inspection. During the inspection Abiodun and Adebola Sanyaolu arrived at the facility. Facility is cited California Code of Regulations Title 22, Division 6, Chapter 1 regulation 80087(a) Buildings and Grounds. Exit interview conducted and a copy of this report was left with Adebola Sanyaolu.

met_with: Abiodun and Adebola Sanyaolu


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Jean Stidman conducted a case management inspection with the above facility on 4/28/26 at 3:00pm and met with Abiodun Sanyaolu, House Manager/Direct Support. On 3/3/26 the facility submitted an incident report regarding a medication error which occurred on 2/25/26. On 2/26/26 the facility submitted an incident report regarding a restraint which occurred on 2/18/26. On 4/7/26 the facility submitted an incident report regarding a restraint which occurred on 2/4/26. All of these incidents were not reported to the licensing agency within the agency's next working day during its normal business hours or within seven days following the occurrence of such event. The facility is cited violation of violation of California Code of Regulations, Title 22, Division 6, Chapter 1, Article 06. Continuing Requirements, regulation 80061(b)(1)(E) Reporting Requirements. An exit interview was conducted, and a copy of this report and appeal rights were provided to Abiodun Sanyaolu, House Manager/Direct Support.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Jean Stidman conducted a case management inspection with the above facility and met with Abiodun Sanyaolu, House Manager/Direct Support. When LPA arrived at 2pm there were no clients present. Present was one staff with their two minor children. During the inspection two other staff and three clients arrived. The facility capacity is for four clients. LPA observed the one staff and their two minor children leave during the inspection. LPA and Abiodun Sanyaolu, House Manager/Direct Support reviewed Title 22, Division 6, Chapter 1, Article 02. License, 80010(a) Limitations on Capacity and Ambulatory Status An exit interview was conducted, and a copy of this report were provided to Abiodun Sanyaolu, House Manager/Direct Support.


summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
another minor. Additionally, four individuals stated a staff did video record the children while on a cruise and one child video recorded scenery on a trip to San Francisco. Neither of these were inappropriate. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be UNSUBSTANTIATED. 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. No title 22 regulations were cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were provided to Abiodun Sanyaolu, House Manager/Direct Support.

Investigation Findings:
13Licensing Program Analyst (LPA) Jean Stidman conducted an unannounced complaint inspection with the above facility on 4/28/26 at 2:00pm and met with Abiodun Sanyaolu, House Manager/Direct Support. The purpose of the inspection was to deliver complaint findings for the above allegation of staff did not prevent a minor from inappropriately recording another minor. On 3/3/ Licensing Program Analyst (LPA), Jean Stidman arrived unannounced at the facility for the purpose of initiating a complaint investigation related to the above allegation. LPA met with Adebola Sanyaolu, Administrator. During the course of the investigation, the following documents were gathered and reviewed: the LIC500, Admission Agreements, Client Roster and the Needs and Services Plan for all youth in care. Confidential interviews were conducted with nine individuals, during the period of 3/3/26 to 4/9/26. LPA's nterviews conducted, and records reviewed were consistent that a minor did not inappropriately record UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jean Stidman 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 SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: JOURNEY OF HOPE XXI INCFACILITY NUMBER: VISIT DATE: 04/28/2026

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

report_type: Complaint Investigation

complaint_status: unsubstantiated


summary: Complaint Investigation - Substantiated - 1 allegation

raw_content:
Narrative:
violation of Title 22, Division 6, Chapter 5, Subchapter 3. Emergency Intervention in Group Homes, Article 08. Emergency Intervention in Group Homes, regulation 84365.5(c) Staffing Requirements. Based on LPA documentation reviewed, and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. An exit interview was conducted, and a copy of this report and appeal rights were provided to Abiodun Sanyaolu, House Manager/Direct Support.

Investigation Findings:
13Licensing Program Analyst (LPA) Jean Stidman conducted an unannounced complaint inspection with the above facility on 4/28/26 at 2:30pm and met with Abiodun Sanyaolu, House Manager/Direct Support. The purpose of the inspection was to deliver complaint findings for the above allegations of staff handled youth in a rough manner. On 3/3/26 at 2:30pm Licensing Program Analyst (LPA), Jean Stidman arrived unannounced at the facility for the purpose of initiating a complaint investigation related to the above allegation. LPA met with Adebola Sanyaolu, Administrator. During the course of the investigation, the following documents were gathered and reviewed: the LIC500, Admission Agreements, Client Roster and the Needs and Services Plan for all youth in care, and text messages regarding the above allegation. Confidential interviews were conducted with nine individuals, during the period of 3/3/26 to 4/9/26. LPA's interviews with six individuals reported, and records reviewed were consistent that one staff conducted a restraint on one child on 2/4/26 and 2/18/26 when no other staff were present. The facility is cited SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jean Stidman 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 SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: JOURNEY OF HOPE XXI INCFACILITY NUMBER: VISIT DATE: 04/28/2026

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

complaint_status: SUBSTANTIATED


facility_name: JOY'S SPECIAL CARE, LLC

raw_content:
Narrative:
On 11/05/2024, Community Care Licensing (CCL) received an allegation that due to a lack of supervision, minors sustained unexplained injuries. It was specifically reported that C1 arrived at school with redness on the left side of C1's forehead and that both the GH and school deny any wrongdoing. During the investigation, multiple confidential interviews determined that C1's injury may have occurred while being transported to school on the school bus but this was not confirmed. In addition, another confidential interview disclosed that when C1 left the facility that day, the injury was not there. Multiple confidential interviews disclosed that there is no concern for lack of supervision at the GH. Based on confidential interviews, the allegation that due to a lack of supervision, minors sustained unexplained injuries is unsubstantiated. The allegation may have happened or be valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Christian Irasusta, Lead Direct Support Professional (DSP).

Investigation Findings:
13On 06/30/2025, at 4:00PM, Licensing Program Analyst (LPA) Maya Chavez conducted an unannounced visit to Joy's Special Care, LLC Group Home (GH) and met with Cristian Irasusta, Lead Direct Support Professional (DSP) to deliver the investigative finding for the allegation listed above. On 11/14/2024, LPA C. Anderson conducted a health and safety inspection at the GH, and no immediate health and safety hazards were observed. In addition, on 05/15/2025, LPA M. Chavez conducted an additional visit at the GH. LPA Chavez conducted interviews with staff (S1 & S2), C1 and C2's Regional Workers, and C1 and C2's School Nurse. LPA Chavez attempted to conduct interviews with C1 and C2 but was unable to due to C1 and C2 being non-verbal. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Maya Chavez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: JOY'S SPECIAL CARE, LLCFACILITY NUMBER: VISIT DATE: 06/30/2025

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


summary: Complaint Investigation - Unsubstantiated - 3 allegations

raw_content:
Narrative:
**Amendment* On 11/06/2024, Community Care Licensing (CCL) received an allegation that facility staff locked minors in their room. It was specifically reported that staff at the group home have reported that the children can be a lot to handle and that sometimes they lock the children in a room. During the investigation, multiple confidential interviews disclosed that staff do not lock C1 and C2 in their bedroom. In addition, a confidential interview disclosed that staff have never mentioned anything about C1 and C2 being locked in their bedroom. Furthermore, a confidential interview disclosed that during showering, bathroom door shall be locked to avoid C1 and C2 running out of the bathroom while wet and naked. LPA did not receive any further information. Based on confidential interviews, the allegation that facility staff locked C1 and C2 in their room may have occurred, however, there was not a preponderance of evidence to prove that the alleged violation, therefore, this allegation is unsubstantiated at this time. An exit interview was conducted, appeal rights explained, and a copy of this report was provided to Christian Irasusta, Lead DSP.

Investigation Findings:
On 06/30/2025, at 4:00PM, Licensing Program Analyst (LPA) Maya Chavez conducted an unannounced visit to Joy's Special Care Group Home (GH) and met with Christian Irasusta, Lead Direct Support Professional (DSP) to deliver the investigative finding for the allegation listed above. On 11/14/2024, LPA C. Anderson conducted a health and safety inspection at the GH, and no immediate health and safety hazards were observed. In addition, on 05/15/2025, LPA M. Chavez conducted an additional visit at the GH. LPA Chavez conducted interviews with staff (S1 & S2), C1 and C2's Regional Workers, and C1 and C2's School Nurse. LPA Chavez attempted to conduct interviews with C1 and C2 but was unable to due to C1 and C2 being non-verbal. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Abdoulaye Traore LICENSING EVALUATOR NAME: Maya Chavez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: JOY'S SPECIAL CARE, LLCFACILITY NUMBER: VISIT DATE: 06/30/2025

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


raw_content:
Narrative:
Confidential interviews reported that staff will intervene during times of aggression to avoid C1 and/or C2 harming themselves. Confidential interviews reported that staff from the facility are not providing sufficient care for C1 and C2 due to inadequate supervision. Confidential interviews denied that any staff had harmed any clients in care at the group home. Based on inconsistent confidential interviews, the allegation that a lack of supervision resulted in minors (C1, C2, C3, and C4) sustaining unexplained injuries while in care is 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, along with the appeal rights, was discussed and provided to Joy Irasusta, Administrator.

Investigation Findings:
13On October 15, 2025, at 11: AM, Licensing Program Analyst (LPA) Cynthia Robinson conducted an unannounced visit to Joy's Special Care, LLC Group Home (GH) to deliver the investigative findings for the allegation listed above. On 03/26/2025, LPA Lucero Jauregui conducted a health and safety inspection at the GH, and no immediate health and safety hazards were observed. LPA obtained documents pertinent to the investigation. LPA Jacob Salem interviewed Staff 1 (S1) and Relatives (R1 and R2). LPA Robinson interviewed clients (C1, C2, C3, and C4), and staff (S2, S3, and S4). On 03/25/2025, Community Care Licensing received an allegation that a lack of supervision resulted in minors (C1 and C2) sustaining unexplained injuries while in care. Confidential interviews reported that C1 and C2, at times, have aggressive behaviors that can cause self-inflicted marks. (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 08-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN DIEGO RO, METROPOLITAN DR. # FACILITY NAME: JOY'S SPECIAL CARE, LLCFACILITY NUMBER: VISIT DATE: 10/15/2025

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

met_with: Joy Irasusta, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On March 17, 2023, at 8: AM, Licensing Program Analyst (LPA) Gloria Meza-Gonzalez conducted an announced inspection. LPA Meza-Gonzalez met with Program Administrator (PA) Jocelyn Irasusta. The purpose of the inspection is to conduct a pre-licensing inspection. This applicant is applying for a group home license with the capacity of 4 ambulatory youths from four to seventeen. The applicant will be receiving Regional Center youth only. LPA Meza-Gonzalez toured the facility with PA Irasusta. The facility is a one-story house with three bedrooms, two bathrooms, two living rooms, a kitchen, a dining room, and a garage. The facility is set up as follows: The first living room has a TV, two couches, a table with three chairs, a coffee table, and a coat closet. LPA Meza-Gonzalez observed games and toys for the client's use. The second living room has two couches, a floor lamp, and a TV. The kitchen has two counter-high chairs, a refrigerator, a stove, a microwave, a stove, and a dishwasher. LPA Meza-Gonzalez observed the stove, microwave, refrigerator, and dishwasher are in working condition. Sharp knives will be inaccessible and stored in a locked cabinet under the kitchen sink. LPA Meza-Gonzalez observed seven days of non-perishable food and two days of perishable food. The dining room has a table and four chairs. The bedrooms are set up as follows: Bedroom # 1: designated for one client, one twin bed, a nightstand, and closet space. Bedroom #2: designated for one client, one twin bed, a nightstand, and closet space. Bedroom #3: designated for two clients, two beds, two nightstands, and closet space. Bedroom #1 and Bedroom #2 share a bathroom in the hallway. Bedroom #3 has a bathroom. Each room has adequate clean linens, pillows, blankets, comforters, mattress pads, and mattresses. The hot water was measured to be 120 degrees Fahrenheit, which is between Community Care Licensing regulations of 105 degrees Fahrenheit to 120 degrees Fahrenheit. See page 2 - LIC809C LPA Meza-Gonzalez observed additional bed linen and towels for clients' use. The washer and dryer are located in the garage. LPA Meza-Gonzalez observed cleaning supplies locked in a cabinet in the garage. The garage is designated as the staff office and will be locked when not in use. Clients' files will be stored in the garage in a locked cabinet. Clients' medication will be stored in a locked cabinet in the garage. The staff files are located off-premises. The staff and clients will always be available to Community Care Licensing as requested The backyard has a table with five chairs, a patio cover, and a shed. The shed has gardening equipment and is locked. The facility's smoke detectors and carbon monoxide detectors were tested and were observed to be in working order; the fire extinguisher is properly charged and serviced. The facility has a fully equipped first aid kit and a first aid manual. The facility does not have cameras. The applicants stated there were no weapons in the home. LPA Meza-Gonzalez observed the following required forms were posted in the facility: menu, personal rights form, grievance/complaint policy, visitation policy, house rules, disaster plan, plan activities, and facility sketch. The fire clearance has been approved. The applicant has been informed that the address of this facility is available to the public. All special incident reports (SIRs) will be sent via e-mail to: cclpaccr@dss.ca.gov. LPA Meza-Gonzalez conducted a component III orientation, a continuing requirement regulation review, with an emphasis on the facility operation and commonly found problem areas. The orientation provided PA Irasusta with sufficient information to operate the facility within substantial compliance, as well as, how to avoid common problem areas for the facility operation. The applicant understands that once the license is approved, all employees and volunteers shall have an approved criminal record clearance for Community Care Licensing and be associated with this facility. Based on this pre-licensing inspection, the facility is in compliance according to Title Regulations. After a final file review, the facility will be submitted for licensure. An exit interview was conducted, and a copy of this report was given to PA Irasusta.

met_with: Jocelyn Irasusta


summary: Facility Evaluation

raw_content:
Narrative:
On May 11, 2023, at 12: PM, Licensing Program Analyst (LPA) Gloria Meza-Gonzalez conducted an unannounced inspection. LPA Meza-Gonzalez met with Program Administrator (PA) Jocelyn Irasusta. The purpose of the inspection is to conduct a post-licensing inspection. The facility is licensed for a capacity of four ambulatory youths from four to seventeen for Regional Center youths only. There are no clients in care at the time of inspection. LPA Meza-Gonzalez toured the facility with PA Irasusta. The facility is a one-story house with three bedrooms, two bathrooms, two living rooms, a kitchen, a dining room, and a garage. The facility is set up as follows: The first living room has a TV, two couches, a table with three chairs, a coffee table, and a coat closet. LPA Meza-Gonzalez observed games and toys for the client's use. The second living room has two couches, a floor lamp, and a TV. The kitchen has two counter-high chairs, a refrigerator, a stove, a microwave, a stove, and a dishwasher. LPA Meza-Gonzalez observed the stove, microwave, refrigerator, and dishwasher are in working condition. Sharp knives will be inaccessible and stored in a locked cabinet under the kitchen sink. LPA Meza-Gonzalez observed seven days of non-perishable food and two days of perishable food. The dining room has a table and four chairs. The bedrooms are set up as follows: Bedroom # 1: designated for one client, one twin bed, a nightstand, and closet space. Bedroom #2: designated for one client, one twin bed, a nightstand, and closet space. Bedroom #3: designated for two clients, two beds, two nightstands, and closet space. Bedroom #1 and Bedroom #2 share a bathroom in the hallway. Bedroom #3 has a bathroom. Each room has adequate clean linens, pillows, blankets, comforters, mattress pads, and mattresses. The hot water was measured to be 120 degrees Fahrenheit, which is between Community Care Licensing regulations of 105 degrees Fahrenheit to 120 degrees Fahrenheit. See LIC809c page LPA Meza-Gonzalez observed additional bed linen and towels for clients' use in the hallway closet. The washer and dryer are located in the garage. LPA Meza-Gonzalez observed cleaning supplies locked in a cabinet in the garage. The garage is designated as the staff office and will be locked when not in use. Clients' files will be stored in the garage in a locked cabinet. Clients' medication will be stored in a locked cabinet in the garage. The staff files are located off-premises. The staff and clients' files will always be available to Community Care Licensing as requested The backyard has a table with five chairs, a patio cover, and a shed. The shed has gardening equipment and is locked. The facility's smoke detectors and carbon monoxide detectors were tested and were observed to be in working order; the fire extinguisher is properly charged and serviced. The facility has a fully equipped first aid kit and a first aid manual. The facility does not have cameras. PA Irasusta stated there were no weapons in the home. LPA Meza-Gonzalez observed the following required forms were posted in the facility: menu, personal rights form, grievance/complaint policy, visitation policy, house rules, disaster plan, plan activities, and facility sketch. The fire clearance has been approved. The applicant has been informed that the address of this facility is available to the public. All special incident reports (SIRs) will be sent via e-mail to: cclpaccr@dss.ca.gov. Based on this post-licensing inspection, the facility is in compliance according to Title Regulations. An exit interview was conducted, and a copy of this report was given to PA Irasusta.


summary: Facility Evaluation

raw_content:
Narrative:
On March 6, 2024, at 10: AM, Licensing Program Analyst (LPA) Carol Anderson conducted an unannounced annual/required inspection. LPA met with Program Administrator (PA)/Licensee Jocelyn Irasusta. Currently there are four clients currently in placement. Four clients were unavailable to be interviewed. LPA interviewed two staff. LPA toured the facility with Licensee/PA Irasusta. The facility is a one-story house with three bedrooms, two bathrooms, two living rooms, a kitchen, a dining room, and a garage. The facility is set up as follows: The first living room has a TV, two couches, a table with three chairs, a coffee table, and a coat closet. LPA observed games and toys for the client's use. The second living room has two couches, a floor lamp, and a TV. The kitchen has two counter-high chairs, a refrigerator, a stove, a microwave, a stove, and a dishwasher. LPA Anderson observed the stove, microwave, refrigerator, and dishwasher are in working condition. Sharp knives will be inaccessible and stored in a locked cabinet under the kitchen sink. LPA Anderson observed seven days of non-perishable food and two days of perishable food. The dining room has a table and four chairs. The bedrooms are set up as follows: Bedroom # 1: designated for one client, one twin bed, a nightstand, and closet space. Bedroom #2: designated for one client, one twin bed, a nightstand, and closet space. Bedroom #3: designated for two clients, two beds, two nightstands, and closet space. Bedroom #1 and Bedroom #2 share a bathroom in the hallway. Bedroom #3 has a bathroom. Each room has adequate clean linens, pillows, blankets, comforters, mattress pads, and mattresses. The hot water was measured to be 112 degrees Fahrenheit, which is between Community Care Licensing regulations. LPA Anderson observed additional bed linen and towels for clients' use in the hallway closet. The washer and dryer are in the garage. LPA Anderson observed cleaning supplies locked in a cabinet in the garage. The garage is designated as the staff office and will be locked when not in use. Clients' files will be stored in the garage in a locked cabinet. Clients' medication will be stored in a locked cabinet in the garage. The staff files are located off-premises. The backyard has a table with five chairs, a patio cover, and a shed. The shed has gardening equipment and is locked. The facility's smoke detectors and carbon monoxide detectors were tested and were observed to be in working order; the fire extinguisher is properly charged and serviced. The facility has a fully equipped first aid kit and a first aid manual. The facility does not have cameras. PA/Licensee Irasusta stated there were no weapons in the home. LPA Anderson observed the following required forms were posted in the facility: menu, personal rights form, grievance/complaint policy, visitation policy, house rules, disaster plan, plan activities, and facility sketch. A review of Guardian on March 6, 2024, indicates that all facility staff associated to the facility had DOJ, FBI, and child abuse index checks clearances. LPA reviewed five client files and five staff files. All necessary forms are in the file. Based on observations made during the inspection, no deficiencies observed during today's visit. An exit interview was conducted, a copy of this report was given to PA/ Licensee Irasusta.

met_with: Jocelyn Irasusta, Licensee


summary: Facility Evaluation

raw_content:
Narrative:
On March 14, 2025 at 1: PM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced visit to the above facility for the purpose of conducting an annual inspection and met with Joceyln Irasusta, Administrator. LPA inspected the facility's physical plant, including personal rights postings, health-related services, buildings and grounds, food services, telephones, indoor and outdoor activity space, and furniture, fixtures, equipment and supplies. The home is clean, in good repair, and free from observable risks to clients' health, safety, and personal rights. The home is a one story building with three client bedrooms and two client bathrooms which are set up as follows: Bedroom #1 has two twin beds and sleeps two clients, bedroom #2 has one twin bed and sleeps one client, and bedroom #3 has one twin bed and sleeps one client. There is a comfortable family and TV room in the front of the home, kitchen and living room area, multiple locked storage closets, and backyard/patio with table for confidential interviews. LPA reviewed the facility's disaster preparedness plan and staff training, which included all the required information and records. LPA reviewed two client files (C1-C2), which are kept in a locked cabinet. The client files reviewed contain required information and records, including pre-placement screenings, personal rights and facility policy acknowledgements, and medication logs. Due to time constraints, the annual is being extended to complete client and staff file reviews, as well as staff interviews. An exit interview was conducted and a signed copy of this report was provided to Joceyln Irasusta, Licensee.

met_with: Joceyln Irasusta, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On March 24, 2025 at 9: AM, Licensing Program Analyst (LPA) Jacob Salem conducted an unannounced visit to the above facility and met with Joceyln Irasusta, Administrator. The purpose of this Case Management inspection is to conduct an annual continuation from 3/14/2025. LPA conducted one staff interview. LPA reviewed two client files (C3-C4), which are kept in a locked cabinet. The client files reviewed contain required information and records, including pre-placement screenings, personal rights and facility policy acknowledgements, medication logs, and court authorization for psychotropic medications. LPA reviewed staff files (S1-S5), which contain the required background clearance and demographic information, health screenings, and qualifications. Based on observations made during the inspection, there were no deficiencies cited at this time. An exit interview was conducted with Joceyln Irasusta, Administrator and a signed copy of this report was provided.


facility_name: JULIE'S HOME

raw_content:
Narrative:
The preponderance of evidence standard has been met, and therefore the above allegations are found to be substantiated. LPA is issuing a citation of California Code of Regulations, Title 22, Division 6, Chapter 5, Article 6, Section 84078, Subsection (b). See attached LIC 9099-D. LPA informed the licensee that due to a violation resulting in serious bodily injury the Licensing Agency may assess an enhanced civil penalty. Should this occur, the licensee will be notified in writing. An exit interview was conducted, and a copy of this report and the licensee's appeal rights were provided to Facility Manager Mariel Pablo, whose signature on this form confirms receipt.

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

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

met_with: Facility Manager Mariel Pablo


summary: Complaint Investigation - Unsubstantiated

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


raw_content:
Narrative:
Although the allegation may have happened or is valid, based on LPA's observations and interviews, there is not a preponderance of the evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report and the licensee's appeal rights were provided to Staff Norman Mabulay.

Investigation Findings:
13On 7/18/25, Licensing Program Analyst (LPA) Mariah Hawkins conducted an unannounced complaint investigation visit at the facility. LPA met with Staff Norman Mabulay and informed of the purpose of the visit. The purpose of the visit was to deliver findings for the investigation of the above allegation. LPA conducted 1 confidential interview. Based on all confidential interviews, observations, and record review, the allegation pertains to black bruising around a nonverbal client's eyes. The client had seizure activity a few days prior to the observation of bruising and also engaged in head-banging self-injurious behavior. The client was observed interacting with staff and did not show signs of neglect, abuse, or discomfort around staff. The facility took the client to the hospital in a timely manner in response to the seizure. Facility staff reportedly did not observe the bruising, but upon being made aware of the bruising, staff consulted medical professionals and took the client to the doctor for assessment. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Isabel Diego LICENSING EVALUATOR NAME: Mariah Hawkins LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 14-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION SAN BRUNO RO, TRAEGER AVE., SUITE FACILITY NAME: JULIE'S HOMEFACILITY NUMBER: VISIT DATE: 07/18/2025

met_with: Staff Norman Mabulay


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Vaishali Singh-Sood conducted an unannounced inspection of the facility on 6/24/2021 at 8: AM. LPA Singh-Sood met with Jane Gano, Administrator. The Group Home is licensed to serve six clients, ages 12-17 years old. The current census is 6 ambulatory clients. The purpose of this inspection was to comply with a regulatory requirement for a yearly required inspection. Adm. took LPA on a walk-through tour of the facility both inside and out. At the time of the inspection, there were 6 clients and 5 staff present. The facility is a single level home, located in San Mateo, CA. The facility consists of five bedrooms, three for clients and two for staff. Staff bedrooms are located in front of the house and are not accessible to clients. There is one bathroom for staff in this area, however it is available to clients if needed. All three client rooms are located in the back of the house with a master bathroom. LPA observed at the time of this inspection, the facility to be clean, safe, and sanitary. LPA observed adequate lighting and space for clothing. The temperature inside the home is 71 degrees Fahrenheit which is in required temperature range, and the water temperature was 117 degrees, which is also in the required range. There was sufficient perishable food for two days and nonperishable food for 7 days. An emergency food supply is kept in the kitchen and garage. Sharps are kept locked in a drawer in the kitchen, and cleaning supplies are kept locked in the garage. The smoke detectors and fire extinguisher are in working order. Nine smoke detectors and two carbon monoxide are all linked in all rooms and hallways located throughout the home. A fire extinguisher is in the kitchen. Medication is stored in locked cabinets in a small office. LPA reviewed the staff and clients files and they had all necessary forms. Four clients are non-verbal, and two speak with very limited ability. However, all clients appeared to be happy with the care they are receiving. The following documents are posted in the facility: facility license, emergency disaster plan, facility sketch, menu, and personal rights. LPA also observed hand sanitizer, lysol and disinfectants in various areas. LPA reviewed the staff and clients files and they had all necessary forms. The Centrally Stored Medication Log and Medication Administration Records were both observed to be in locked cabinets in a small office. A review of Licensing Information System on June 23, 2021 indicates that all facility staff associated to the facility had DOJ, FBI and child abuse index check clearances. There were no deficiencies cited at today's inspection. Exit interview was conducted at 2: PM, and a copy of the report was emailed to Administrator Jane Gano.

met_with: Jane Gano


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Cheyenne McCambridge conducted an unannounced inspection of the facility for the purpose of conducting an Annual/Required inspection. LPA McCambridge met with Administrator Jane Gano. The Group Home is licensed to serve six clients, ages 12-17 years old. The current census is 6 ambulatory clients. Four clients are non-verbal, and two speak with very limited ability LPA McCambridge toured the facility both inside and out. At the time of the inspection, there were no clients and one staff present. The facility is a single level home, located in San Mateo, CA. The facility consists of five bedrooms, three for clients and two for staff. Staff bedrooms are located in front of the house and are not accessible to clients. There is one bathroom for staff in this area, however it is available to clients if needed. All three client rooms are located in the back of the house with a master bathroom. LPA observed at the time of this inspection, the facility to be clean, safe, and sanitary. Required documents are posted throughout the facility. LPA observed adequate lighting and space for clothing. The temperature inside the home is 71 degrees Fahrenheit which is in required temperature range, and the water temperature was 117 degrees, which is also in the required range. There was sufficient perishable food for two days and nonperishable food for 7 days. An emergency food supply is kept in the kitchen and garage. Sharps are kept locked in a drawer in the kitchen, and cleaning supplies are kept locked in the garage. The smoke detectors and fire extinguisher are in working order. Nine smoke detectors and two carbon monoxide are all linked in all rooms and hallways located throughout the home. A fire extinguisher is in the kitchen. Medication is stored in locked cabinets in a small office. LPA reviewed the staff and clients files and observed to be complete and current with all necessary forms. LPA observed medication logs to be updated and current. There were no deficiencies cited at today's inspection. Exit interview was conducted and a copy of the report was emailed to Administrator Jane Gano.


summary: Facility Evaluation

raw_content:
Narrative:
On 6/20/23, Licensing Program Analyst (LPA) Mariah Hawkins conducted a required annual inspection. LPA conducted a screening call with Administrator Jane Gano and met on site with Facility Manager Mariel Pablo. Administrator arrived shortly after LPA's arrival. The CARE Inspection Tool was used to complete this inspection. All residents were at school at the start of this visit. The faciity serves a developmentally disabled population. LPA conducted a tour of the facility and grounds, interviewed 2 staff, and reviewed 5 staff files and 5 resident files. Two residents arrived from school during the visit and were observed to be clean and dressed in clean, well-fitting clothes. Residents appeared very comfortable with staff, and staff were very attentive to residents and maintained strong supervision of, and engagement with, residents. LPA observed the facility site and grounds to be clean, organized, and free of hazards. Beds have clean linens, including mattress pads and top and bottom linens. Bedrooms are double-occupancy, and each resident has their own bed. The kitchen and bathroom were both in sanitary condition. Chemicals and dangerous items are locked away where inaccessible to the residents in care. Medications are stored appropriately and administration is logged appropriately. The kitchen is stocked with more than enough food to meet the needs of the residents in care. Hot water measured within permitted range. No deficiency citations were issued at today's visit. An exit interview was conducted, appeal rights discussed, and a copy of this report was left with Administrator Jane Gano, whose signature on this form confirms receipt.

met_with: Administrator Jane Gano


summary: Facility Evaluation

raw_content:
Narrative:
On 7/26/23 at 3PM, Licensing Program Analyst (LPA) Mariah Hawkins and Licensing Program Manager (LPM) met with Administrator Jane Gano and Golden Gate Regional Center Case Manager Martha Tercero. The purpose of the meeting was to discuss the transition plan for residents whose ages exceed the licensed age range. Currently, the facility has 5 residents in care, and three are 18 or older, with one of these residents being age 22. The Licensing agency is not able to approve an age exception for residents 22 or older. The Administrator was previously advised that age exception requests for all residents 18 or older would need to be submitted. As of today, one request has been received, and two are still in progress. Licensee acknowledges that the facility is currently operating out of compliance and agrees to complete the following (refer to LIC Confidential Names): - Licensee will work with R1's authorized representative to locate an adult home placement for resident R1 and transition R1 into new placement within 30 days, by Friday 8/25/23. - If R1 will not be moved to a new placement by 8/25/23, licensee will submit, by 8/25/23, a transition plan to have R1 moved out to an adult placement. - Licensee will submit age exception requests for R2 and R3 with support letters from authorized representatives. These will be submitted by 8/25/23. A copy of this report was provided to Administrator Jane Gano, who agreed to receive a digital copy, sign, and return to LPA.


summary: Facility Evaluation

raw_content:
Narrative:
On 6/14/24, Licensing Program Analyst (LPA) Mariah Hawkins made a visit to the facility for a required annual inspection. LPA met with House Lead Maria Pablo and informed of the purpose of the visit. LPA toured the facility site and inspected facility records. LPA observed the facility to be clean, dangerous items such as knives, chemicals, and medications were stored where only accessible to staff, and the bathroom and kitchen spaces were clean and sanitary. Resident bedrooms were tidy, offered activity space, and personal items were neatly folded and stored in the closets. LPA also observed residents to be dressed in clean, well-fitting clothes. All residents are nonverbal. LPA observed staff provide close supervision and engagement to each resident and to communicate effectively with each other in caring to each resident's needs as they ate lunch, engaged in individual activities, used the bathroom, and returned from school. LPA observed the resident records to be complete with required documentation. A continuation inspection is required to complete the review of personnel records. However, LPA verified that all staff on site have a background clearance and eligibility to work at the facility. As stated above, a continuation visit will be conducted. No deficiencies were observed during today's inspection. An exit interview was conducted, appeal rights were discussed, and a copy of this report was left with House Lead.

met_with: House Lead Maria Pablo


summary: Facility Evaluation

raw_content:
Narrative:
On 5/19/26, Licensing Program Analyst (LPA) Celeste Aparicio conducted a required annual inspection. LPA met with Administrator Jane Gano and informed of the purpose of the visit. During the inspection there were two(2) clients and three(3) staff present in the facility. Using the CARE Inspection Tool, LPA inspected the facility site and grounds and reviewed five(5) staff files and (4) client records. LPA observed the facility site and grounds to be maintained in safe condition. There is a large supply of food in the refrigerator, freezers, and cabinets. Bathrooms and kitchen are sanitary. There are three double-occupancy bedrooms, currently sleeping four clients. There are activities and toys available to the clients. LPA observed client records and staff records to be complete. Clients' medications are stored appropriately and medication administration records reflect correct administration. All staff have current crisis intervention training. All clients in care are nonverbal/non-conversational, so LPA did not conduct any client interviews. LPA conducted one staff interview due staff being preoccupied with assigned job duties. LPA conducted observations of all clients and present staff at the end of the inspection. (report continued on LIC809-C) Staff schedule was obtained along with updated copies of the following documents:LIC309, LIC500, LIC402, and LIC610C. Administrator will send in copy of updated LIC308 to LPA Aparicio. LPA is issuing two (2) technical violations for 84063(a)(10) and 84063(a)(9)Accountability due to facility not ensuring that minutes are kept for all board of directors meetings and retained as a permanent record. The minutes shall reflect the board's discussion of documents and these minutes not being available to view for licensing agency to inspect, audit, and copy upon demand during normal business hours. LPA is also issuing a technical assistance for 80075(f)Health Related Services for only one of five staff members not possessing a qualified American Red Cross CPR recertification. S2 had a recertification from an organization that was not qualified by American Red Cross. (See LIC9102's attached dated 5/19/26 and LIC Confidential Names dated 5/19/26) No deficiency citations were issued at today's inspection. An exit interview was conducted, and a copy of this report, attachments, were provided the the Administrator.

met_with: Administrator, Jane Gano


facility_name: KAVERE AT GREEN MOUNTAIN

summary: Facility Evaluation

raw_content:
Narrative:
An unannounced annual required inspection was conducted by Licensing Program Analyst (LPA) Tana Kinder on 12/06/2021 at 11: AM. LPA Kinder confirmed prior to the inspection that no staff or clients were experiencing health symptoms related to Covid19. Criminal record clearances were reviewed, and the facility is in compliance. The licensing fees are current. Community Care Licensing file, unusual incident reports, facility roster, facility profile and complaint history were reviewed prior to inspecting the facility. The Group Home is licensed for 4 youth and has 2 youth currently placed. There are 7 staff members currently working at the facility. The facility is in the process of hiring 2 additional staff for Sunday shifts. LPA reviewed 5 staff files. Files reviewed were incomplete. 2 child files were also reviewed. Documentation included emergency contact information, date of placement and personal rights. The charts were complete. The facility was inspected jointly with LPA and Administrator, Rhonda Reid, and the facility is in compliance. A copy of the license, personal rights and emergency exit plan are prominently posted. Client and staff files are in locked cabinets, located in the office. Smoke detectors are in working order, there is a carbon monoxide monitor located in the hallway. A fully charged fire extinguisher is located in the entry and laundry room. There are 4 bedrooms with 1 bed in each bedroom. Each client is provided with a bed, dresser, closet space and a night stand. The 2 bedrooms in use had personal affects. There is 1 bathroom accessible to the clients. There is a hall closet with additional linen if needed for the bedrooms and the bathroom. The kitchen was accessible by the clients. There is a monthly menu posted that is being followed. There was enough perishable/non-perishable food for 2 clients to last 3/8 days. LPA tested the water temperature at multiple faucet locations the reading was between 107.1-110.8 degrees. There is a back patio area, accessible by the youth. The walkway from the front to the back of the facility was clear. The facility vehicle has current insurance and registration. Exit interview conducted and discussed with Rhonda Reid, Administrator, and a copy of the inspection report was provided, including violations and technical violations.

met_with: Program Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst, (LPA) Tana Kinder conducted an unannounced inspection for the purpose of reviewing documentation for the technical violations from the Annual Inspection dated 12/6/2021. LPA reviewed the documentation for staff and client files. The documentation is consistent with CCL regulation requirements. No citations were issued. A copy of this report was provided to the facility.

met_with: DSP Staff


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst, (LPA) Tana Kinder conducted an inspection on 4/26/2022 at 115pm with the Program Director for the purpose of confirming the relocation of the facility. Documentation will be submitted prior to the pre-inspection. All clients (3) have been moved from the current facility to appropriate placements that were coordinated with the Regional Center and their families. There was no evidence of clients living on the premises. All personal belongings and furnishings were removed. No citations were issued. An exit interview was conducted and a copy of this report was provided.

met_with: Program Director


facility_name: KAVERE SERVICES-PINE BROOK HOME

raw_content:
Narrative:
All incident reports were documented and sent out properly. Medication logs were audited daily, and all medicine was verified and double checked by another staff member before administering to clients. All staff members have certification to administer medication to clients. Staff client ratios were met and scheduled according to the census of the facility LPA observed medication timers and medication logs filled out on time and signed. Facility has a checks and balances system for administering medication to the clients. No errors were found in medication logs. Staff schedule always had over the client to staff ratio scheduled. LPA found that the allegation was UNSUBSTAINTIATED. 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 was left with administrator Jai Thompson

Investigation Findings:
13On 11/1/ Licensing Program Analyst (LPA) Rob Sandles met with administrator Jai Thompson at the above facility for the purpose of delivering complaint findings. LPA Sandles requested the following documents: Needs and service plan for all clients in the home, Placement history of facility, Staff trainings for last year, Staff schedule, and Medication Logs LPA interviewed three staff, one administrator, 2 clients in care and a Service Coordinator LPA reviewed requested documents. The allegations are that staff do not provide adequate supervision to the minors while in care, staff are not administering a minor's medication as prescribed, facility has inadequate record keeping and staff did not properly report an incident involving minors while in care. LPA observed through interviews, file review and observation that the medication logs were filled out correctly. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Robert Sandles 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: KAVERE SERVICES-PINE BROOK HOMEFACILITY NUMBER: VISIT DATE: 11/01/2021

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

met_with: Jai Thompson


raw_content:
Narrative:
On 1/12/23, 1/27/23, 2/8/23, 2/17/ IB conducted interviews with three staff, two clients and one prior staff. Confidential interviews revealed inconsistent statements of the incident or how the injury occurred. Based on IB's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be unsubstantiated. 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. No title 22 regulations were cited during today's inspection. Exit interview conducted and a copy of this report was left with Marisa Corral, Administrator.

Investigation Findings:
13Licensing Program Analyst (LPA) Jean Stidman, conducted an unannounced inspection to the facility on 3/24/23 at 1:30pm to deliver complaint allegation findings. LPA met with Marisa Corral, Administrator and discussed the above allegation. During the investigation of Staff hit a child causing injuries to the face, LPA Stephannie Verna toured the facility with Marissa Corral, Administrator on 1/11/23. On this inspection, LPA Verna met with Marissa Corral, Administrator and informed them of the above allegation and that a complaint investigation is in process and will be conducted by CDSS Investigative Branch (IB). On 1/6/23, 1/12/23, 1/17/23, 1/23/ IB investigator Jami Eaton reviewed documentation of Licensing Information System, Field Automated System, Facility personnel report dated 1/11/23, staff schedule for January 2023, client documentation of Individual Program Plan dated 9/22/22, picture of client's bruised lip taken on 1/3/23, client progress notes for 1/1/23 and 1/2/23 and texts from staff to the administrator regarding the incident. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jean Stidman 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: KAVERE SERVICES-PINE BROOK HOMEFACILITY NUMBER: VISIT DATE: 03/24/2023

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

met_with: Marisa Corral, Administrator


raw_content:
Narrative:
unsubstantiated. 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. No title 22 regulations were cited during today's inspection. Exit interview conducted and a copy of this report was left with Marissa Corral, Administrator.

Investigation Findings:
13Licensing Program Analyst (LPA) Jean Stidman, conducted an unannounced inspection to the facility on 6/6/23 at 9:15am to deliver complaint allegation findings. LPA met with Marissa Corral Administrator and discussed the above allegation. During the investigation of facility does not have adequate staffing to supervise youth in care, LPA toured the facility with Marissa Corral Administrator on 1/23/23. On this inspection, LPA obtained documentation for the complaint investigation of current staff's ProAct training, work schedules and client rosters for December 2022 and January 2023. LPA conducted interviews of four staff on 1/23/23, one staff interview on 1/24/23, and the reporting party on 1/26/23. Records reviewed on 1/25/23, 3/13/23 and 5/19/23 revealed the facility had a minimum staff ratio of one staff for four clients during the overnight shift. Then during the day and swing shifts the facility had at minimum one staff for every two clients and at maximum two staff for every client. Interviews revealed that the facility maintains the required staff to child ratio as required by Title 22 regulation 84065.5. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jean Stidman 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: KAVERE SERVICES-PINE BROOK HOMEFACILITY NUMBER: VISIT DATE: 06/06/2023

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

met_with: Marissa Corral Administrator


raw_content:
Narrative:
LPA conducted interviews on 11/20/23, 11/21/23, 2/28/24, and 3/5/24 with the reporting party, four staff and observed the client due to them not being able to participate in an interview. Three out of five confidential interviews reported the client is well groomed and has difficulties allowing the staff to trim their nails due to their diagnosis. Records reviewed showed the client's nails are checked daily and from 6/20/22-8/21/23 the client had marks on their neck on five separate occasions from being self-inflicted. One the day in question, the client had gotten into make-up and it had stained their skin. LPA observed the client to be well groomed and their fingernails did not appear long or uncut. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No title 22 regulations were cited during today's inspection. Exit interview conducted and a copy of this report was left with Marissa Corral Administrator.

Investigation Findings:
13Licensing Program Analyst (LPA) Jean Stidman conducted an unannounced inspection to the facility on 3/7/24 at 4pm to deliver complaint allegation findings. LPA met with Marissa Corral Administrator and discussed the above allegations. During the investigation of minor sustained unexplained marks while in care and staff does not ensure minor's hygiene needs are being met, LPA toured the facility with Marissa Corral Administrator on 11/21/23. On this inspection, LPA inspected the physical plant inside and out, reviewed one client file and obtained documentation for the complaint investigation of Face Sheet, Identification and Emergency Information, admission agreement, needs and services plans for 2022 -2023, physician's reports for 2022 and 2023, behavior intervention plan, individual program plan, quarterly reports for 2023, doctor visit for November 2023, weight record, progress notes-behavior logs for 10/31/23-11/20/23, hygiene tasks for 10/27/23-11/23/23, body check forms for 6/20/22, 6/21/22, 7/18/22, 8/6/23, and 8/21/23, and support team visit rating forms for 12/29/22, 2/15/23, and 11/5/23. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jean Stidman 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 SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: KAVERE SERVICES-PINE BROOK HOMEFACILITY NUMBER: VISIT DATE: 03/07/2024


raw_content:
Narrative:
four children. Seven out of seven interviews with staff AD, S1, S2, S3, S5. S6, and S7 all reported not witnessing or having knowledge of any staff yelling or speaking in appropriately to clients. Interviews with clients C3 & C4 did not report any concerns with not feeling comfortable in the facility. It should be noted that the staff S4 who was alleged in this complaint is on an extended leave and was not interviewed for this complaint and that C1 and C2 are non-verbal and would not participate in an interview. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No title 22 regulations were cited during today's inspection. Exit interview conducted and a copy of this report to provided to Marissa Corral, Administrator.

Investigation Findings:
13Licensing Program Analyst (LPA) Jean Stidman conducted an unannounced inspection to the facility or agency on 12/16/24 at 11am to deliver complaint allegation findings. LPA met with Marissa Corral, Administrator, and discussed the above allegations. During the investigation of staff member yelled at minor, staff member inappropriately spoke to minor, staff member did not provide a comfortable environment for minor, LPAs Sarina Buchannan and Sara Luman-Gonzalez toured the facility with Marissa Corral, Administrator on 8/19/24 and LPAs Jean Stidman and Maie Soliman on 11/6/24 and LPA Stidman on 12/9/24. On these inspections, LPAs inspected the physical plant inside and out and reviewed four client's files. On 8/19/24 and 11/6/ Licensing Program Analyst (LPA) Jean Stidman obtained four children's Needs and Services Plans, staff training logs, client roster and LIC Personnel Report, one child's Identification and Emergency Information, Admission Agreement and case notes for July 2024. LPAs conducted interviews on 11/6/24, 11/21/24 and 12/9/24 with seven staff and UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Jean Stidman 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 SACRAMENTO CRP RO, GOETHE ROAD, SUITE FACILITY NAME: KAVERE SERVICES-PINE BROOK HOMEFACILITY NUMBER: VISIT DATE: 12/16/2024

met_with: Marissa Corral, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPAs) Jean Stidman and Cecilia Warren made an unannounced (Annual inspection on 4/28/22 at 12:45pm. During the inspection LPAs met with Regina Webb Lead Staff who assisted with the inspection. LPA (analyst name) conducted a walk-through of the facility inside and out. Facility staff-client ratio at time of inspection is 2 staff to 4 clients. Number of staff interviewed Number of clients interviewed LPAs observed # 3 bedrooms, # 3 bathrooms LPAs inspected and/or reviewed the following: I. Physical Plant II. Operations III. Disaster Preparedness IV. Emergency Intervention V. Staffing/Volunteers VI. Client Records VII. Core/Therapeutic Services VIII. Special Health Care Needs (SHCN) An exit interview was conducted and a copy of this report was left with Regina Webb Lead Staff.

met_with: Regina Webb Lead Staff


summary: Facility Evaluation - 1 deficiency

raw_content:
Narrative:
Licensing Program Analyst (LPA) Jean Stidman made an unannounced Annual inspection on 6/2/23 at 9am. During the inspection LPA met with Isaac Herrera, Administrator, who assisted with the inspection. LPA Stidman conducted a walk-through of the facility inside and out. Facility staff-client ratio at time of inspection with two staff and three clients present. One additional client arrived at 1:30pm. Number of staff interviewed _three_ Number of clients interviewed _four_ LPA observed # _three_bedrooms, # _three bathrooms. LPA Stidman inspected and/or reviewed the following: I. Physical Plant Posting of license_X__ Personal Rights__X___ Disinfectants/Cleaning solutions inaccessible__X___ Refrigerator Temperature at or below 45 degrees F __X___ Freezer Temperature at or below 0 degrees__X___ Nonperishable Foods one week and fresh perishable foods two days minimum__X___ Menu present and posted__X____ Working telephone __X_ Carbon monoxide detectors __X_Smoke Detector _X__ First Aid Kit fully stocked_X__ Common Room available__X__ Dining area (enough seating, furniture good condition, not broke or damaged) __X_ Medication centrally stored, locked/inaccessible _X_ Office (locked and privacy) _X_ Hot Water between 105-120 degree F (Properly labeled if over 125 degree F__116 degrees_ Fire Extinguisher May 2023. Toilets wash basin, bath and shower fixtures in good repair/no leaks/hot water temperature _x Soap and Paper towels __X_ Laundry Facilities(available, work assign dates) __X___ Bedrooms-required linen and furnishings __X___ Motor Vehicle properly maintained , lights, tires, registration/insurance and working seat belts_____ Facility free of vermin _X__ Bedroom (required bedding/furniture, furniture in good repair) __X___ II. Operations Complaint Procedures For Youth Reviewed __X____ Board Minutes Reviewed__X___ III.Disaster Preparedness Disaster and mass casualty plan updated and available__X_ Quarterly Drills conducted and documented__X_____ Disaster preparedness supplies verified __X__ IV.Emergency Intervention Review of manual restraint log __X_ Staff training _X___ V.Staffing/Volunteers Number of Staff files reviewed __three Criminal record clearances verified _three___ First Aid Certificate__X__ Certified Administrators certificate valid and current__X_ VI.Client Records Number of Clients files reviewed _four__Needs and Services Plan _four_ Centrally Stored Medication and log reviewed __four_ Psychotropic Medication and log reviewed __X___Cash Resources__X__ The following items were reviewed for compliance: · Annual fees · Administrator Certificate for: Isaac Herrera, Administrator · Emergency Disaster Plan (per H&S Code 1565) · Annual Emergency Intervention Log · Personnel Roster, Facility Sketch, LIC500, LIC610C and LIC308. An exit interview was conducted with Isaac Herrera, Administrator and a copy of this report was left with Isaac Herrera, Administrator.

Deficiencies:
84068.3(a): Modifications to Needs and Services Plan

(a) The needs and services plan specified in Section 84068.2 shall be updated at least every six months to determine the following

met_with: Isaac Herrera, Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On 3/7/ Licensing Program Analyst (LPA) Jean Stidman met with Marissa Corral Administrator for the purpose of a Case Management Inspection. LPA discussed California Code of Regulation, Title 22, Regulation Administrator Qualifications and Duties. No further investigation is needed. Exit interview conducted and a copy of this report was left with Marissa Corral Administrator.


facility_name: KAVERE SERVICES-PRINCETON HOME

raw_content:
Investigation Findings:
13Licensing Program Analysts (LPAs) Jean Stidman and Cecilia Warren conducted an unannounced inspection to the facility on 6/14/22 at 11:45am to deliver complaint allegation findings. LPA met with Isaac Herrera, Administrator and discussed the above allegations. During the investigation of staff physically abused minor, staff verbally abused minor, staff threatened minor and staff broke minor's toy. LPA toured the facility with Amanda Gulley Administrator on 4/5/22 and with Shayla Tommila Social Worker on 5/23/22. On these inspections, LPA inspected the physical plant inside and out and no concerns were observed, reviewed one client file, one staff file and obtained documentation for the complaint investigation. LPA conducted interviews on 4/21/22 and 5/12/22. Confidential interviews and documentation reviewed revealed all the allegations are substantiated. Based on LPA's observations, interviews which were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 5, #84072(d)(11), are being cited on the attached LIC 9099D. Exit interview conducted and a copy of this report and a copy of the appeal rights were left at the facility with Isaac Herrera, Administrator. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Dara Campos LICENSING EVALUATOR NAME: Cecilia Warren 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: KAVERE SERVICES-PRINCETON HOMEFACILITY NUMBER: 397005954

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


summary: Facility Evaluation

raw_content:
Narrative:
On 2/25/ Licensing Program Analyst (LPA) Jean Stidman met with Amanda Gulley for the purpose of an Annual Inspection. LPA reviewed two client files and four staff files. LPA inspected the facility inside and outside. No deficiencies cited.

met_with: Amanda Gulley Administratot


summary: Facility Evaluation

raw_content:
Narrative:
On 4/5/ Licensing Program Analysts (LPAs) Jean Stidman and Uchenna Ajaero met with Amanda Gulley Administrator for the purpose of investigating an incident that occurred on 3/31/22. LPAs reviewed one client file and one staff file. LPAs received some documentation from these files and requested more documentation from these files be sent via email.

met_with: Amanda Gulley Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Jean Stidman made an unannounced Annual inspection on 2/2/23 at 9:30 am. During the inspection LPA met with Marissa Corral Administrator who assisted with the inspection. LPA conducted a walk-through of the facility inside and out. Facility staff-client ratio at time of inspection 0 staff and 0 clients were present when the inspection began. Number of staff interviewed Number of clients interviewed _0_ LPA observed # 2 bedrooms, # 2 bathrooms LPA Stidman inspected and/or reviewed the following: I. Physical Plant Posting of license_X_ Personal Rights__X_ _ Disinfectants/Cleaning solutions inaccessible__X_ Refrigerator Temperature at or below 45 degrees F _X_ Freezer Temperature at or below 0 degrees_X_ Nonperishable Foods one week and fresh perishable foods two days minimum__X Menu present and posted_X_ Working telephone_X_ Carbon monoxide detectors _X_ Smoke Detector _X_ First Aid Kit fully stocked_X__ Common Room available_X Dining area (enough seating, furniture good condition, not broke or damaged) _X_ Medication centrally stored, locked/inaccessible _X_ Office (locked and privacy) _X_Hot Water between 105-120 degree F (Properly labeled if over 125 degree F_ DEGREES___ Fire Extinguisher (note inspection date) Dec Toilets wash basin, bath and shower fixtures in good repair/no leaks_X_ Soap and Paper towels _X_ Laundry Facilities(available, work assign dates) _X_ Bedrooms-required linen and furnishings _X_ Motor Vehicle properly maintained , lights, tires, registration/insurance and working seat belts_X_ Facility free of vermin _X_ Bedroom (required bedding/furniture, furniture in good repair) _X_ During the inspection LPA observed the hot water temperature was 134 degrees Fahrenheit. LPA observed staff lowered the hot water heater. II. Operations Complaint Procedures For Youth Reviewed X_ Board Minutes Reviewed_X_ III.Disaster Preparedness Disaster and mass casualty plan updated and available_X__ Quarterly Drills conducted and documented___X_ Disaster preparedness supplies verified __X__ IV.Emergency Intervention Review of manual restraint log __X_ Staff training _X_ V.Staffing/Volunteers Number of Staff files reviewed _2_Criminal record clearances verified_X_ First Aid Certificate_X_ Certified Administrators certificate valid and current___x__ Job title/qualification verified __X Hours required training verified__X__ Hours required annual training verified _X__ VI.Client Records Number of Clients files reviewed ___2___Needs and Services Plan _2___ Centrally Stored Medication and log reviewed _2__ Psychotropic Medication Consent forms Reviewed _X_ Psychotropic Medication and log reviewed __x___Cash Resources_x__ VII. Core/Therapeutic Services Trauma Informed Practices are implemented as needed (including specialty mental health services and extracurricular activities and social supports) _X VIII. Special Health Care Needs (SHCN) N/A An exit interview was conducted with Marissa Corral Administrator and a copy of this report was left with Marissa Corral Administrator. Facility citation violation of California Code of Regulations, Title 22, Division 6, regulation 80088(e)(1) Fixtures, Furniture, Equipment and Supplies. During the inspection on 11/15/22 & 12/22/22 the water temperature was 134 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care. The facility turned the hot water temperature down during the inspection.


summary: Facility Evaluation

raw_content:
Narrative:
On 2/2/ Licensing Program Analyst (LPA) Jean Stidman met with Marissa Corral Administrator for the purpose of continuing an Annual Inspection, LPA interviewed one client. An exit interview was conducted with Marissa Corral Administrator and a copy of this report was left with Marissa Corral Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
Licensing Program Analyst (LPA) Jean Stidman made an unannounced Annual inspection on 9/28/23 at 9:15am. During the inspection LPA met with Isaac Herrera, Administrator, who assisted with the inspection. LPA Stidman conducted a walk-through of the facility inside and out. Facility staff-client ratio at time of inspection with two staff and no clients were present. Two additional staff and two clients arrived during the inspection, Number of staff interviewed _four_ Number of clients interviewed one LPA observed # _two_bedrooms, # _two bathrooms. LPA Stidman inspected and/or reviewed the following: I. Physical Plant Posting of license_X_ Personal Rights__X___ Disinfectants/Cleaning solutions inaccessible__X___ Refrigerator Temperature at or below 45 degrees F 41 degrees Freezer Temperature at or below 0 degrees_-3 degrees F Nonperishable Foods one week and fresh perishable foods two days minimum__X___ Menu present and posted__X____ Working telephone __X_ Carbon monoxide detectors __X_Smoke Detector _X__ First Aid Kit fully stocked_X__ Common Room available__X__ Dining area (enough seating, furniture good condition, not broke or damaged) __X_ Medication centrally stored, locked/inaccessible _X_ Office (locked and privacy) _X_ Hot Water between 105-120 degree F (Properly labeled if over 125 degree F__127.5 degrees_ Fire Extinguishers inspected December 2022. Toilets wash basin, bath and shower fixtures in good repair/no leaks/hot water temperature _x Soap and Paper towels __X_ Laundry Facilities(available) __X___ Bedrooms-required linen and furnishings __X___ Motor Vehicle properly maintained, lights, tires, registration/insurance and working seat belts_X__ Facility free of vermin _X__ Bedroom (required bedding/furniture, furniture in good repair) __X___ II. Operations Complaint Procedures For Youth Reviewed __X____ Board Minutes Reviewed__X___ III.Disaster Preparedness Disaster and mass casualty plan updated and available__X_ Quarterly Drills conducted and documented__X_____ Disaster preparedness supplies verified __X__ IV.Emergency Intervention Review of manual restraint log __X_ Staff training _X___ V.Staffing/Volunteers Number of Staff files reviewed _five Criminal record clearances verified _five_ First Aid Certificate__five__ Certified Administrators certificate valid and current__X_ VI.Client Records Number of Clients files reviewed two Needs and Services Plan two Centrally Stored Medication and log reviewed two Psychotropic Medication and log reviewed __X___Cash Resources__N/A__ Facility citation violation of California Code of Regulations, Title 22, Division 6, regulation 80088(e)(1) Fixtures, Furniture Equipment and Supplies due to the hot water temperature was 127.5 degrees F. LPA observed facility staff turned down the hot water heater during the inspection. The following items were reviewed for compliance: · Annual fees · Administrator Certificate for: Isaac Herrera, Administrator · Emergency Disaster Plan (per H&S Code 1565) · Annual Emergency Intervention Log · Personnel Roster, Facility Sketch, LIC500 and LIC610C. An exit interview was conducted with Isaac Herrera, Administrator and a copy of this report was left with Isaac Herrera, Administrator.


summary: Facility Evaluation

raw_content:
Narrative:
On 12/7/ Licensing Program Analyst (LPA) Jean Stidman met with Amanda Gulley, Senior Director, for the purpose of conducting a case management inspection. After a review of Kavere Services Pine Brook, Pinetown and Princeton facility's January - July 2023 incident reports for 17 separate medication errors for the Kavere Services Pine Brook, Pinetown and Princeton facilities LPA discovered seven occurred while the clients were on home visits, one occurred while the clients were at school, eight occurred in the facility due to staff errors and one incident occurred at the facility and at school. LPA reviewed the 17 incident reports and the Kavere Medication Policy PowerPoint Slides, three client's medication logs. LPA observed the PowerPoint has 72 slides and observed some slides have information that is duplicated on multiple slides, some information is inconsistent such as the number of Medication Rights varies between five to eight. LPA provided Amanda Gulley, Senior Director, with a list of the 17 incidents and a list of suggested revisions to the PowerPoint slides. Exit interview conducted and a copy of this report was left with Amanda Gulley, Administrator.

met_with: Amanda Gulley, Senior Director


summary: Facility Evaluation

raw_content:
Narrative:
On 6/13/ Licensing Program Analyst (LPA) Jean Stidman met with Richard Herrera, Executive Administrator, for the purpose of closing this facility. LPA conducted an inspection of the facility and verified there are no children present. The children and the facility files have been moved to Pinetown facility. The original license was surrendered to LPA. No violations were cited. No further investigation is needed. The facility is closed effective 6/13/24. LPA provided a copy of this report to Richard Herrera Executive Administrator on this date.

met_with: Richard Herrera Executive Administrator