summary: Facility Evaluation

raw_content:
Narrative:
On September 16, 2025 at 09: AM, Licensing Program Analyst (LPA) Lucero Jauregui conducted an unannounced annual facility inspection. LPA met with Erica Rowan, Residential Supervisor who provided LPA with a guided indoor and outdoor tour of the facility. The facility serves a capacity of 14, age range 12-17 years old upon intake with a current census of 12 clients. The facility has two cottages. Cottage one is a six bedroom, two bathroom, dinning area, living room, and staff office. Cottage 2 is a five bedroom, two bathroom, kitchen, laundry room, dinning area, living room, and staff office. All bedrooms serve one client each. All beds were observed with appropriate linens, pillows, comforters, and mattresses in good repair. Each cottage living room has a TV, chairs, and board games for indoor activities. Each Cottage had combined living spaces of dinning and living room area. The dinning area contained a large dinning table with six chairs. The kitchen in Cottage two was observed to be free from hazards. The kitchen contained a walk in pantry where it was observed to have supplies of staple non- perishable foods for a minimum of one week and fresh perishable food for a minimum of two days. Sharps were maintained in a lock box in the pantry. Medication was stored in the staff office of each cottage in locked cabinets. Controlled medications were in a locked cabinet in a locked safe. The facility contained security bags for when clients go on day passes. A physical plant inspection was completed and included the following checks: Facility grounds are clean and free of debris and observable hazards. There is adequate indoor and outdoor activity space. Sports equipment/toys/books/games were observed for children's recreation time. Continued.... NAME OF LICENSING PROGRAM MANAGER: Dawn Segura NAME OF LICENSING PROGRAM ANALYST: LUCERO JAUREGUI LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/16/ I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. Facility Representative Signature: Date: 09/16/ California Health & Human Services Agency California Department of Social Services FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form. DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies: Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care. Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care. PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency. CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given. CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity. PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency. APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC Applicant/Licensee Rights. AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency. EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency. LIC809 (FAS) - (09/23)Page: 2 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) California Department of Social Services Community Care Licensing Division San Diego Ro, Metropolitan Dr. # San Diego, CA There is a large backyard for outdoor activities. There is a picnic table in the front and back yard. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. The hot water temperature was measured in the bathroom to be 106. Per Program Administrator there are no firearms in the facility. LPA observed the following items posted Personal Rights, Foster Youth Bill of Right, Emergency Disaster Plan, Facility License, If you See Something Say Something, Meal Menu, Activity Schedule, Laundry Schedule, Chore Schedule and Important Phone Numbers for clients. There are two separate buildings on grounds. Cottage three is the staff office. Cottage four is the family center with a sensory room. In addition, there are two sheds for the maintenance coordinator. Client files are maintained electronically. Personnel files were maintained electronically by Human Resources (HR). LPA reviewed twelve client files. LPA reviewed five electronic staff files via Microsoft Teams with HR. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Based on today's visit there are no deficiencies observed at this time. An exit interview was conducted, a copy of this report along with appeal rights was provided to Roland Williams, Program Administrator. NAME OF LICENSING PROGRAM MANAGER: Dawn Segura NAME OF LICENSING PROGRAM ANALYST: LUCERO JAUREGUI LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/16/ I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. Facility Representative Signature: Date: 09/16/ NAME OF LICENSING PROGRAM MANAGER: Dawn Segura NAME OF LICENSING PROGRAM ANALYST: LUCERO JAUREGUI LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/16/ I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. Facility Representative Signature: Date: 09/16/ California Health & Human Services Agency California Department of Social Services FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form. DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies: Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care. Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care. PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency. CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given. CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity. PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency. APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC Applicant/Licensee Rights. AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency. EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency. LIC809 (FAS) - (09/23)Page: 2 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) California Department of Social Services Community Care Licensing Division San Diego Ro, Metropolitan Dr. # San Diego, CA There is a large backyard for outdoor activities. There is a picnic table in the front and back yard. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. The hot water temperature was measured in the bathroom to be 106. Per Program Administrator there are no firearms in the facility. LPA observed the following items posted Personal Rights, Foster Youth Bill of Right, Emergency Disaster Plan, Facility License, If you See Something Say Something, Meal Menu, Activity Schedule, Laundry Schedule, Chore Schedule and Important Phone Numbers for clients. There are two separate buildings on grounds. Cottage three is the staff office. Cottage four is the family center with a sensory room. In addition, there are two sheds for the maintenance coordinator. Client files are maintained electronically. Personnel files were maintained electronically by Human Resources (HR). LPA reviewed twelve client files. LPA reviewed five electronic staff files via Microsoft Teams with HR. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Based on today's visit there are no deficiencies observed at this time. An exit interview was conducted, a copy of this report along with appeal rights was provided to Roland Williams, Program Administrator. NAME OF LICENSING PROGRAM MANAGER: Dawn Segura NAME OF LICENSING PROGRAM ANALYST: LUCERO JAUREGUI LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/16/ I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. Facility Representative Signature: Date: 09/16/ NAME OF LICENSING PROGRAM MANAGER: Dawn Segura NAME OF LICENSING PROGRAM ANALYST: LUCERO JAUREGUI LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/16/ I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. Facility Representative Signature: Date: 09/16/ California Health & Human Services Agency California Department of Social Services FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form. DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies: Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care. Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care. PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency. CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given. CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity. PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency. APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC Applicant/Licensee Rights. AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency. EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency. LIC809 (FAS) - (09/23)Page: 2 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) California Department of Social Services Community Care Licensing Division San Diego Ro, Metropolitan Dr. # San Diego, CA There is a large backyard for outdoor activities. There is a picnic table in the front and back yard. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. The hot water temperature was measured in the bathroom to be 106. Per Program Administrator there are no firearms in the facility. LPA observed the following items posted Personal Rights, Foster Youth Bill of Right, Emergency Disaster Plan, Facility License, If you See Something Say Something, Meal Menu, Activity Schedule, Laundry Schedule, Chore Schedule and Important Phone Numbers for clients. There are two separate buildings on grounds. Cottage three is the staff office. Cottage four is the family center with a sensory room. In addition, there are two sheds for the maintenance coordinator. Client files are maintained electronically. Personnel files were maintained electronically by Human Resources (HR). LPA reviewed twelve client files. LPA reviewed five electronic staff files via Microsoft Teams with HR. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Based on today's visit there are no deficiencies observed at this time. An exit interview was conducted, a copy of this report along with appeal rights was provided to Roland Williams, Program Administrator. NAME OF LICENSING PROGRAM MANAGER: Dawn Segura NAME OF LICENSING PROGRAM ANALYST: LUCERO JAUREGUI LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/16/ I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. Facility Representative Signature: Date: 09/16/ NAME OF LICENSING PROGRAM MANAGER: Dawn Segura NAME OF LICENSING PROGRAM ANALYST: LUCERO JAUREGUI LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/16/ I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. Facility Representative Signature: Date: 09/16/ California Health & Human Services Agency California Department of Social Services FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form. DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies: Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care. Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care. PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency. CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given. CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity. PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency. APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC Applicant/Licensee Rights. AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency. EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency. LIC809 (FAS) - (09/23)Page: 2 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) California Department of Social Services Community Care Licensing Division San Diego Ro, Metropolitan Dr. # San Diego, CA There is a large backyard for outdoor activities. There is a picnic table in the front and back yard. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. The hot water temperature was measured in the bathroom to be 106. Per Program Administrator there are no firearms in the facility. LPA observed the following items posted Personal Rights, Foster Youth Bill of Right, Emergency Disaster Plan, Facility License, If you See Something Say Something, Meal Menu, Activity Schedule, Laundry Schedule, Chore Schedule and Important Phone Numbers for clients. There are two separate buildings on grounds. Cottage three is the staff office. Cottage four is the family center with a sensory room. In addition, there are two sheds for the maintenance coordinator. Client files are maintained electronically. Personnel files were maintained electronically by Human Resources (HR). LPA reviewed twelve client files. LPA reviewed five electronic staff files via Microsoft Teams with HR. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Based on today's visit there are no deficiencies observed at this time. An exit interview was conducted, a copy of this report along with appeal rights was provided to Roland Williams, Program Administrator. NAME OF LICENSING PROGRAM MANAGER: Dawn Segura NAME OF LICENSING PROGRAM ANALYST: LUCERO JAUREGUI LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/16/ I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. Facility Representative Signature: Date: 09/16/ NAME OF LICENSING PROGRAM MANAGER: Dawn Segura NAME OF LICENSING PROGRAM ANALYST: LUCERO JAUREGUI LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/16/ I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. Facility Representative Signature: Date: 09/16/ California Health & Human Services Agency California Department of Social Services FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form. DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies: Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care. Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care. PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency. CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given. CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity. PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency. APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC Applicant/Licensee Rights. AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency. EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency. LIC809 (FAS) - (09/23)Page: 2 of STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) California Department of Social Services Community Care Licensing Division San Diego Ro, Metropolitan Dr. # San Diego, CA There is a large backyard for outdoor activities. There is a picnic table in the front and back yard. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. The hot water temperature was measured in the bathroom to be 106. Per Program Administrator there are no firearms in the facility. LPA observed the following items posted Personal Rights, Foster Youth Bill of Right, Emergency Disaster Plan, Facility License, If you See Something Say Something, Meal Menu, Activity Schedule, Laundry Schedule, Chore Schedule and Important Phone Numbers for clients. There are two separate buildings on grounds. Cottage three is the staff office. Cottage four is the family center with a sensory room. In addition, there are two sheds for the maintenance coordinator. Client files are maintained electronically. Personnel files were maintained electronically by Human Resources (HR). LPA reviewed twelve client files. LPA reviewed five electronic staff files via Microsoft Teams with HR. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Based on today's visit there are no deficiencies observed at this time. An exit interview was conducted, a copy of this report along with appeal rights was provided to Roland Williams, Program Administrator. NAME OF LICENSING PROGRAM MANAGER: Dawn Segura NAME OF LICENSING PROGRAM ANALYST: LUCERO JAUREGUI LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/16/ I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. Facility Representative Signature: Date: 09/16/ There is a large backyard for outdoor activities. There is a picnic table in the front and back yard. All facility smoke detectors and carbon monoxide detectors are in appropriate working order; fire extinguisher is properly charged and serviced. The hot water temperature was measured in the bathroom to be 106. Per Program Administrator there are no firearms in the facility. LPA observed the following items posted Personal Rights, Foster Youth Bill of Right, Emergency Disaster Plan, Facility License, If you See Something Say Something, Meal Menu, Activity Schedule, Laundry Schedule, Chore Schedule and Important Phone Numbers for clients. There are two separate buildings on grounds. Cottage three is the staff office. Cottage four is the family center with a sensory room. In addition, there are two sheds for the maintenance coordinator. Client files are maintained electronically. Personnel files were maintained electronically by Human Resources (HR). LPA reviewed twelve client files. LPA reviewed five electronic staff files via Microsoft Teams with HR. All appropriate personnel who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions. Based on today's visit there are no deficiencies observed at this time. An exit interview was conducted, a copy of this report along with appeal rights was provided to Roland Williams, Program Administrator.


state: CA

facility_name: FRED FINCH YOUTH CENTER-SAN DIEGO

summary: Facility Evaluation

raw_content:
Narrative:
On 8/4/2022 at 1: PM, Licensing Program Analyst (LPA) Marisol Lopez conducted an unannounced case management at the above facility and met with Program Administrator (P1) Roland Williams. The purpose of the case management is to follow-up on information received by community care licensing. On 02/24/2022, the Department received information that client #1(C1) overdosed on 02/14/2022 resulting in hospitalization and C1 was transported to the hospital on due to an overdose on medications. Confidential interviews and documents provided determined the facility did not follow Fred Finch's home visit medication policy. LPA reviewed the pass medication form and the form was incomplete missing the counter signature by the caregiver. Fred Finch Home Visit Medications Policy: The Medical Coordinator receives notification of a participant's home visit via a social worker communication at least 24 hours before visit. The pharmacy prepares the proper amount to be sent with the participant on his/her home visit. A completed Home Visit Medications Form must accompany a participant for any home visits and be counter signed by a residential staff and the caregiver. A copy of the signed form will be retained for FFYC records and a copy provided to the caregiver for reference. Based on confidential interviews and record review, the facility did not operate in accordance with the terms specified in the plan of operation and the pass medication form was incomplete. This poses an immediate health, safety, or personal rights risk to residents in care. The facility is being cited for violation of California Code of Regulations, Interim Licensing Standards 80022(h) Plan of Operation . An exit interview was conducted and a copy of this report and LIC 811 was given to Program Administrator Roland Williams.

report_type: Facility Evaluation

visit_type: Case Management

met_with: Roland Williams


facility_name: FRED JEFFERSON MEMORIAL HOME #1

summary: Complaint Investigation - Unsubstantiated - 1 allegation

raw_content:
Narrative:
Special Incident Report # 809823, Child & Family Team notes, Needs & Service Plan, Staff work schedules, facilities emergency intervention policies and procedures. Pro Act certifications. Staff #3 denied hitting Child #2 and stated was working in the office when Child #2 rushed and attacked Staff #3 in office. Staff #1, Staff #2, & Staff #4 all denied allegations and stated Staff # 3 was rushed and attacked by client. Child #2 stated did square off with Staff # 3 and stepped into the office but did not want to fight. Staff #3 & Staff #4 attempted to de escalation but Child #2 & Child #1 rushed Staff # 3 shoving Staff #3 into office wall. Staff #4 stated used Pro Act De escalation techniques to calm Child #1 & Child #2. Photographs show evidence of impact to office wall. Based on the interviews conducted and documentary evidence, the information gathered did not produce corroborating evidence to support the above said allegation. LPA Phillips was not able to determine if the above said allegations occurred, therefore the allegations are determined to be unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that a violation occurred. Based on the observations made during today's inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. Exit interview was conducted, and a copy of this report will be emailed to Yvonne Robinson/ Administrator.

Investigation Findings:
13On June 8, 2022 at 12: PM Licensing Program Analyst (LPA), Zena Phillips conducted a follow-up complaint investigation visit to FRED JEFFERSON MEMORIAL HOME #1 and met with Heather Boucher/Facility Manager. The purpose of the visit was to deliver findings for the above complaint allegation. During the investigation of the allegations: Staff hit minor resulting in bruising. During the investigation of the allegations: LPA Phillips interviewed two(2) clients ,six (6) staff and two (2) children's social workers. LPA Phillips reviewed facility files and conducted confidential interviews with relevant parties. After conducting the confidential interviews and reviewing the following documentation: UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Zena Phillips LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: FRED JEFFERSON MEMORIAL HOME #1FACILITY NUMBER: VISIT DATE: 06/08/2022

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

report_type: Complaint Investigation

met_with: Heather Boucher/Facility Manager

complaint_status: unsubstantiated


summary: Facility Evaluation

raw_content:
Narrative:
On November 2, 2021 at 8:43am, Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to Fred Jefferson Memorial Home for Boys #1 to conduct an annual required inspection at the above location. The facility is licensed to provide care and supervision for six (6) children, ages 14-17 years old, ambulatory only. This facility also provides services to non-minor dependents pursuant to W&I Code 16501.1(C)(1). Provisional license extended through 11/20/2021. Waiver on file. Currently there are three (3) clients in placement. There is no swimming pool or bodies of water on the premises. LPA Edison met with Heather Boucher (Facility Manager) who granted access into the home and together a tour of the home was conducted. The home is a single-story home located in a residential neighborhood. The home has 3 bedrooms, 2 bathrooms, living room, kitchen, laundry area, an office, a meeting room, front and a backyard. No bodies of water on the premises. Living Room: There is adequate furniture which appears to be in good condition. There is a locked room off of the living room which contains 2 refrigerators for extra frozen foods, meats, dairy products. There is a locked cabinet inside of the room that contains extra hygiene products and extra linens. Kitchen: Equipped with refrigerator, 4 burner gas stove, oven, and microwave. There is adequate perishable and nonperishable food supply. Facility provides nutritious snacks between meals. Dining Area: (located in Kitchen) One table with six chairs Bedroom 1: Is not occupied on the date of inspection. It is equipped with two twin beds, two dressers, adequate lighting and closet space. Bedroom 2: Occupied by one client, equipped with two twin beds, two dressers, adequate lighting and closet space. Bedroom 3: Occupied by two clients, equipped with two twin beds, two dressers, adequate lighting and closet space. Bathroom 1: (located in Meeting room) Toilets, sinks, and showers clean and operable at time of visit. Bathroom 2: Toilets, sinks, and showers clean and operable at time of visit. Meeting Room: is located along the hallway, it has table with six (6) chairs, and there is a locked closet that is used for food storage. Office: Is located along the hallway and contains staff and client files in locked file cabinets. Also contains a locked closet which holds extra snacks and non-perishable foods. Continued on LIC 809-C The home was inspected, and the following was observed: The home is clean, safe, and sanitary. Sharp knives, disinfectants/cleaning solutions, and medicines are made inaccessible to clients. Hot water kept at a safe temperature. The beds have comfortable mattresses, clean linens, blankets and pillows, all in good repair. Caregiver maintains a safe and comfortable temperature in the home. First aid kit was checked and found to have appropriate supplies. Fire extinguishers located in the meeting room, laundry room, and kitchen were fully charged All smoke detectors and carbon monoxide detectors tested audible and were working properly. Emergency numbers, facility license, evacuation plan, and first aid information were posted. No guns or weapons are in the home. There is a working telephone readily accessible to clients in the home at all times. Children's Personal Rights and house rules are posted. Outdoor activity space is free of obstruction. During this visit, LPA conducted 2 client interviews and 3 staff interviews. LPA informed Administrator of past due licensing fees. Administrator will contact Financial Executive to find out the status of fees being paid. Administrator will update LPA of fees being paid. LPA advised administrator of Mental Health waiver expiration date of 11/20/2021. Administrator spoke with the Head of Service who advised approval should be received by 11/12/2021. Administrator will email the approval certificate to LPA Edison. LPA will return at a later date to complete the inspection. An exit Interview was conducted, and a copy of this report will be emailed to the facility.

visit_type: Annual

met_with: Janeal Brent-Administrator


summary: Facility Evaluation

raw_content:
Narrative:
Myron Smith - Facility Manager (Staff 1) S Janeal Brent - Administrator (Staff 2) S Dr. Shreipha Myvett - Head of Mental Health Service (Staff 3) S On November 12, 2021 at 11:00am, Licensing Program Analyst (LPA) Daphne Edison made an announced visit to Fred Jefferson Memorial Home for Boys #1 to conduct a case management annual continuation inspection which took place on November 2, 2021 at the above location. The facility is licensed to provide care and supervision for six (6) children, ages 14-17 years old, ambulatory only. This facility also provides services to non-minor dependents pursuant to W&I Code 16501.1(C)(1). Provisional license extended through 11/20/2021. Waiver on file. The census on the date of this visit is three (3). There is no swimming pool or bodies of water on the premises. LPA Edison met with Staff 1 (S1), who granted access into the home. The home is a single-story home located in a residential neighborhood. The home has 3 bedrooms, 2 bathrooms, living room, kitchen, laundry area, an office, a meeting room, front and a backyard. There is no swimming pool or bodies of water on the premises. LPA observed facility vehicle used to transport clients is in good repair with valid CA vehicle registration and valid proof of insurance. Continued on LIC 809C LPA reviewed following during the inspection: Staff Records Review: LPA reviewed five (5) staff records stored in individual personnel file/binders provided by the facility manager. LPA ensured to thoroughly review the records of the primary active staff (i.e The Program Administrator, Primary Therapist, Clinical Director, Residential Director, Facility Manager; and Five (5) Direct Care Staff. LPA reviewed the Personnel Report (LIC 500) and confirmed that Direct Care Staff Ratio present for the three (3) clients in placement. In review of the staff's records confirmed that All staff have required criminal record clearance. DOJ, FBI and Child Abuse Response. Client Records Review: LPA reviewed three (3) client records stored in individual personnel file/binders provided by the facility manager. LPA thoroughly reviewed the records of the clients including the Needs and Services Plan for each client along with Personal Rights. LPA spoke with Staff 3 (S3), by telephone while present at the facility and advised that Mental Health waiver expires on November 20, 2021. LPA was advised by S3 that approval should be received before expiration date and will be emailed to LPA. LPA provided email information to S3. Facility cited for violation of California Code of Regulations, Title Division Six, regulation Administrator - Qualifications and Duties. The current administrator does not meet educational/experience qualifications and was not an administrator of a group home prior to January 1, 2017. Has a certificate of a group home administrator effective 5/20/2018 and expires 5/20/2020. An exit Interview was conducted, and a copy of this report will be emailed to the facility.

met_with: Myron Smith - Facility Manager


facility_name: FRED JEFFERSON MEMORIAL HOME #2

raw_content:
Investigation Findings:
13On August 23, 2021 at 9: AM Licensing Program Analyst (LPA), Mercy Gago made an announced visit to the above facility for the purpose of conducting a complaint investigation. LPA Gago informed the Facility Administrator, Dr. Shermin Mitchell, that the above-mentioned allegations investigated by the Community Care Licensing Division (CCLD),has been completed. On May 13, 2021, LPA Gago observed that NSP's were updated on a monthly basis, however, several were missing CSW/DPO signatures. Efforts to maintain school of origin documentation was not in NSP. There were incomplete Life books. The Facility Administrator provided LPA Gago with a copy of the most recent SIR training to Staff that was conducted on 4/22/21. The facility Administrator reported that all Staff have been trained on emergency intervention training within 30 days of hire and Copies of the Pro-Act Certificate were submitted to CAD. The Facility Administrator reported that Special Incident Reporting are being submitted timely. Based on information obtained this investigation is being closed Unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the allegations occurred. No deficiencies cited. Exit interview completed. A copy of this report was left with facility Staff. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Alan Henry LICENSING EVALUATOR NAME: Mercy Gago LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

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

met_with: Dr. Shermin Mitchell, Facility Administrator


raw_content:
Narrative:
Supporting evidence include the following: Staff #1, Facility Manager, Facility Manager #1, Facility Manager #2, & Facility Manager #3 denied the above stated allegations. Child # Child #3 and Staff #1 stated Staff #1 was sitting down when the altercation started. Child #3 stated wanted to get some punches in when altercation started. Child #3 admitted just jumped in on impulse throwing punches.while Staff #1 was seated. Child #2 stated jumped in to help Child #1 out and was mad hitting Staff #1 with metal chair. Staff # 1 admitted trying to protect self and put up hands to block punches and may have hit Child #1 but not intentional. There is no corroborating evidence to support that staff intentionally injured child or intentionally caused bruises to child. Based on the interviews conducted and documents obtained, the above allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or disprove that a violation occurred. Based on the observations made during today's inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. Exit interview was conducted, and a copy of this report will be emailed to the Administrator

Investigation Findings:
13On June 8, 2022 at 8: AM Licensing Program Analyst (LPA), Zena Phillips conducted a follow-up complaint investigation visit to FRED JEFFERSON MEMORIAL HOME #2 and met with Janeal Brent/ Facility Manager.The purpose of the visit was to deliver findings for the complaint allegations. During the investigation of the allegations: Minor was physically abused while in care. Staff caused injuries to minor while in care. LPA Phillips reviewed facility file and conducted confidential interviews with relevant parties. After conducting the confidential interviews and reviewing the following documentation: Special Incident Reports (SIR), Staff schedule,Client files, NSP,CFT, & Pro Act certificate. Police report not recieved at this time. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Lakescia Smith LICENSING EVALUATOR NAME: Zena Phillips LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of Control Number 34-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, N. Continental Blvd. #290B FACILITY NAME: FRED JEFFERSON MEMORIAL HOME #2FACILITY NUMBER: VISIT DATE: 06/08/2022

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

met_with: Janeal Brent/Facility Manager


summary: Facility Evaluation

raw_content:
Narrative:
On November 16, 2021 at 9:01am Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to FRED JEFFERSON MEMORIAL HOME #2 for the purpose of a conducting a Required Annual Inspection. LPA met with Facility Manager Temeka Curtis who granted access to the facility and a tour was conducted. The home is licensed to provide care and supervision to six (6) children ages 14-17 years old, ambulatory only. The census on the date of this visit is six (6). This facility also provides services to non-minor dependents pursuant to W&I Code 16501.1(C)(1). Provisional license extended through 11/20/2021. Waiver on file. There are no pools or bodies of water on the premises. The home was inspected, and the following was observed: The home is clean, safe, sanitary, and in good repair. Sharp knives, disinfectants/cleaning solutions, and medicines are made inaccessible to the children. Hot water kept at a safe temperature. The beds have comfortable mattresses, clean linens, blankets and pillows, all in good repair. Caregiver maintains a safe and comfortable temperature in the home. First aid kit was checked and found to be appropriate. The fire extinguisher(s) were fully charged. All smoke detectors and carbon monoxide detectors tested audible and were working properly. Emergency numbers, facility license, evacuation plan, and first aid information were posted. No guns or weapons are in the home. There is a working telephone readily accessible to clients in the home at all times. Children's Personal Rights and house rules are posted. There is an exit door located off the laundry room leading to a side of the home. Outdoor activity space is free of obstruction. Motor vehicle used to transport clients is maintained in a safe operating condition and has valid and current California Vehicle Registration and insurance. Continued on LIC 809C During this visit, LPA conducted 3 client interviews. Children in care are supervised and protected at all times. Children are accorded dignity in personal relationships with staff and others. Children can contact the licensing agency or Foster Care Ombudsperson in confidence without threats or punishment for making complaints. It was reported by Facility Manager that children attend school, extracurricular, cultural and personal enrichment activities. LPA conducted 3 staff interviews. The home is operating within the capacity and limitations of the license. Adminstrator advised Mental Health approval will be emailed to LPA by 11/20/2021. No deficiencies were observed or cited. An exit Interview was conducted, and a copy of this report will be emailed to the licensee. The facility is set up as follows: This is a single-story home located in a residential neighborhood. The home has 3 bedrooms, 1 bathroom, 1/4 bathroom, living room, dining room, kitchen, detached garage, laundry area, small attached back room with a conference room that has a table and six (6) chairs and a locked cabinet with extra food storage. The conference room has an office for use by staff where client files are kept locked. There is a locked cabinet in the office for extra hygiene products and Personal Protective Equipment (PPE). Any medications are stored in a locked cabinet in the office. The backyard is clean and free of obstruction. All bedrooms contain an exit window with working security bars. Living Room: There is adequate furniture which appears to be in good condition. Kitchen: Kitchen was equipped with refrigerator, 4 burner gas stove, oven, and microwave. There is adequate perishable and nonperishable food supply. Facility provides nutritious snacks between meals. Dining Area: One table with six chairs Bedroom #1: Occupied by two (2) clients and is equipped with two twin size beds, a dresser, and has adequate closet space. Bedroom #2: Occupied by two clients and is equipped with two twin size beds, a dresser, and has adequate closet space. Bedroom # 3: Occupied by two clients and is equipped with two twin size beds, a dresser, and has adequate closet space. Bathroom #1: 1/ Bathroom equipped with a toilet and sink for staff use. Clean and operable at the time of visit. Bathroom 2: Full bathroom equipped with toilet, sink, cabinets, and shower for clients use. Clean and operable at the time of the visit. Continued on LIC 809C

met_with: Temeka Curtis


summary: Facility Evaluation

raw_content:
Narrative:
On November 19, 2021 at 9:40am Licensing Program Analyst (LPA) Daphne Edison made an unannounced visit to FRED JEFFERSON MEMORIAL HOME #2 to conduct a case management annual continuation inspection which took place on November 16, 2021 at the above location. LPA met with Facility Manager Temeka Curtis who granted access to the facility. The home is licensed to provide care and supervision to six (6) children ages 14-17 years old, ambulatory only. The census on the day of this visit is six (6). This facility also provides services to non-minor dependents pursuant to W&I Code 16501.1(C)(1). Provisional license extended through 11/20/2021. Waiver on file. LPA reviewed following during the inspection: Staff Records Review: LPA reviewed five (5) staff records stored in individual personnel files provided by the facility manager. LPA ensured to thoroughly review the records of two (2) primary active staff (i.e Administrator, Facility Manager) and three (3) Direct Care Staff. LPA reviewed the Personnel Report (LIC 500) and confirmed that Direct Care Staff Ratio present for the six (6) clients in placement. In review of the staff's records confirmed that all staff have required criminal record clearance. DOJ, FBI and Child Abuse Response. Client Records Review: LPA reviewed six (6) client records stored in individual personnel files provided by the facility manager. LPA thoroughly reviewed the records of the clients including the Needs and Services Plan for each client along with Personal Rights. LPA requested and was provided with a current Mental Health Program Approval certificate valid November 18, 2021 through November 17, 2022 and valid CARF accreditation extended through October 31, Facility cited for violation of California Code of Regulations, Title Division Six, regulation Administrator - Qualifications and Duties. The designated administrator does not meet Administrator qualifications nor have a STRTP administrator certificate. An exit Interview was conducted, and a copy of this report will be emailed to the facility.


summary: Facility Evaluation

raw_content:
Narrative:
On February 8, 2022 at 8:30am Licensing Program Analysts (LPAs), Emelyn Sanchez P. and Olivia Rosas arrived at the above facility unannounced for the purpose of conducting a SB Psychotropic Medication Case Management- Medication Inspection Visit. LPAs Sanchez P. and Rosas met with Janeal Brent, Facility Manager. LPAs Sanchez P. and Rosas reviewed no client files due to current placements not taking any psychotropic medication. However LPAs Sanchez P. and Rosas reviewed three (3) staff files and conducted three (3) staff interviews. Currently there are five (5) clients residing in the above facility. This is a facility located in a residential area and equipped with three (3) bedrooms, one (1) staff office, two (2) bathrooms, living room, dining room, kitchen, and laundry space. There are no bodies of water on the premises. Common areas area clean and in good repair. Rooms are fully furnished with two beds, and closet space. Outdoor space is free of obstructions. LPAs Sanchez P. and Rosas observed the facility to be clean, safe, sanitary and in good repair. LPAs Sanchez P. and Rosas observed adequate staffing in the facility to provide care and supervision to children in care. LPAs Sanchez P. and Rosas also observed medication to stored in the staff office, triple locked and inaccessible to clients and unauthorized staff members. There were no deficiencies cited at this time. Exit interview was conducted, and a copy of this report was left at the facility.

met_with: Janeal Brent


summary: Facility Evaluation

raw_content:
Narrative:
On September 21, 2022 at 8: AM Licensing Program Analyst (LPA) Zena Phillips made an unannounced visit to FRED JEFFERSON MEMORIAL HOME #2 for the purpose of a conducting a Required Annual Inspection. LPA met with Facility Manager Freda Forrest who granted access to the facility. The home is licensed to provide care and supervision to six (6) children ages 14-17 years old, ambulatory only. This facility also provides services to non-minor dependents. The census on the date of this visit is four (4). There are no pools or bodies of water on the premises. LPA reviewed following during the inspection: Client Records Review: LPA reviewed four (4) client records provided by the facility administrator. LPA thoroughly reviewed the records of the clients including the Needs and Services Plan for each client along with Personal Rights. LPA conducted three (3) staff interviews. LPA interviewed two (2) Facility Managers and one (1) Administrator during inspections. The two (2) clients present in the home declined to be interviewed. The other two (2) clients were not present during inspection due to school attendance. LPA observed the following during the inspection: Children's Personal Rights and house rules are posted. There is an exit door located off the laundry room leading to a side of the home. Outdoor activity space is free of obstruction. Motor vehicle used to transport clients is maintained in a safe operating condition and has valid and current California Vehicle Registration and insurance. cont on 809c LPA reiterated the importance of submitting Special Incident Reports and reporting all changes within the facility to Community Care Licensing and any other appropriate agency. Caregiver(s)/adults working in the home have DOJ/FBI criminal record clearances and Child Abuse Index Checks. The home is operating within the capacity and limitations of the license. No deficiencies were observed or cited. LPA advised Administrator will return at a later date to complete Annual Inspection. An exit Interview was conducted, and a copy of this report will be emailed to Licensee.

met_with: Yvonne Robinson / Administrator


summary: Facility Evaluation

raw_content:
Narrative:
On September 26, 2022 at 9: AM Licensing Program Analyst (LPA) Zena Phillips made a announced visit to FRED JEFFERSON MEMORIAL HOME #2 for the purpose of a conducting a Required Annual Inspection. LPA met with Facility Manager Phyllis Ross who granted access to the facility and a tour was conducted. The home is licensed to provide care and supervision to six (6) children ages 13-17 years old, ambulatory only. The census on the date of this visit was three (3). This facility also provides services to non-minor dependents. There are no pools or bodies of water on the premises. The home was inspected, and the following was observed: The home is a one story building located in a residential neighborhood. Sharp knives, disinfectants/cleaning solutions, and medicines are made inaccessible to the children. LPA observed plenty of hygiene products available for residents use. Hot water kept at a safe temperature. The home has three (3) bedrooms with one full & half bathrooms all in good repair. Each bedroom has two (2) twin beds, 2 dresser drawers with five (5) drawers and ceiling fans all observed to be in good condition. The hall closet has multiple shelves fully stocked with extra towels and clean bed linens. The living room has two (2) large sofas, coffee table, television, bookcase with books and games. The dining table has seating for eight (8). . cont on 809c The kitchen stove has four (4) burners and LPA confirmed all igniting properly. There was adequate fresh fruit and vegetables available for residents .The weekly menu was posted, refrigerator has adequate food all labeled and properly stored The freezer had additional foods all properly stored in sealed containers and or bags. Caregiver maintains a safe and comfortable temperature in the home. First aid kit was checked and found to be appropriate. The fire extinguisher(s) were fully charged. All smoke detectors and carbon monoxide detectors tested audible and were working properly. Emergency numbers, facility license, evacuation plan, and first aid information were posted. No guns or weapons are in the home. There is a working telephone readily accessible to clients in the home at all times. Children's Personal Rights and house rules are posted. LPA reviewed following during the inspection: Staff Records Review: LPA reviewed five (5) staff records stored in individual personnel files provided by the Administrator LPA ensured to thoroughly review the records of three (3) Facility Managers and two (2) Direct Care Staff. LPA observed staff completed Trauma Informed Care Part 1 & Part 2 and observed valid CPR certificates in personnel file. LPA requested copy of emergency disaster plan and provided. LPA reviewed the Personnel Report (LIC 500) and confirmed that Direct Care Staff Ratio present for the three (3) clients in placement. In review of the staff's records confirmed that all staff have required criminal record clearance. DOJ, FBI and Child Abuse Response. LPA requested that board meeting minutes be forwarded to LPA's email address. An exit Interview was conducted, and a copy of this report will be emailed to the facility administrator.


facility_name: FRESNO YOUTH-PALO ALTO HOUSE

summary: Complaint Investigation - Unsubstantiated

raw_content:
Investigation Findings:
13On January 12, 2023, Licensing Program Analyst (LPA) Wayne Aoki conducted a follow up complaint inspection. The purpose of this inspection is to close and deliver the findings for the above complaint allegation. LPA was me by facility representative Mandy Perez. Although the allegation may have happened or is valid, based on the confidential interviews that were conducted by the LPA and copies of documents that were obtained, there is not a preponderance of the evidence. Therefore, the above allegation is unsubstantiated. There were no deficiencies cited during this inspection. A copy of this report along with appeals rights were left with the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Wayne Aoki LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3

met_with: Mandy Perez


raw_content:
Investigation Findings:
13On December 13, 2023, Licensing Program Analyst (LPA) Briana Placencia conducted a complaint inspection at Fresno Youth Palo Alto and met with Mandy Perez. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the investigation, LPA conducted interviews, a records review and reviewed supporting documents provided by the facility. Based on confidential interviews and other information obtained, the department has made the following determination. Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Briana Placencia LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3


investigation_findings: 13On December 13, 2023, Licensing Program Analyst (LPA) Briana Placencia conducted a complaint inspection at Fresno Youth Palo Alto and met with Mandy Perez. The purpose of the inspection was to deliver the findings for the above complaint allegation. During the investigation, LPA conducted interviews, a records review and reviewed supporting documents provided by the facility. Based on confidential interviews and other information obtained, the department has made the following determination. Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Briana Placencia LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 3


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Reyna Martinez conducted a complaint inspection and met with Mandy Perez. The purpose of the inspection was to deliver the findings for the above complaint allegation. The Department has investigated the complaint alleging Staff did not seek timely medical attention for a minor. LPA conducted confidential interviews and obtained documentation.There were inconsistencies in the confidential interviews. Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Reyna Martinez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


raw_content:
Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Reyna Martinez conducted a complaint inspection and met with Mandy Perez. The purpose of the inspection was to deliver the findings for the above complaint allegations. The Department has investigated the complaint alleging Staff did not prevent an inappropriate sexual interaction between the minors. LPA conducted confidential interviews and obtained documentation.There were inconsistencies in the confidential interviews. Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was left at the facility. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Reyna Martinez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


summary: Complaint Investigation - Substantiated

raw_content:
Investigation Findings:
13On the above date, Licensing Program Analysts (LPA) Reyna Martinez conducted a complaint inspection to the STRTP and met with Mandy Perez. The purpose of the inspection was to deliver the findings for the above complaint allegation. Based on interviews it was determined that Staff did not properly report an incident involving minors to Community Care Licensing. Based on the LPA's observations, confidential interviews and records review which were conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be substantiated. A deficiency is being cited for the California Code of Regulations (CCR) Title 22, Division 6, Chapter 1, Article 06, 80061(a) Reporting Requirements. A copy of the report and Appeal Rights was provided to the STRTP. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Juanita Arroyo LICENSING EVALUATOR NAME: Reyna Martinez 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 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE FACILITY NAME: FRESNO YOUTH-PALO ALTO HOUSEFACILITY NUMBER: 107204098

complaint_status: SUBSTANTIATED


summary: Facility Evaluation

raw_content:
Narrative:
An unannounced SB Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian on 02/04/2022 at 10:30AM. During the inspection, LPA Melikian met with Rita Johnson, Program Director and inspected the facility inside and out. LPA reviewed four children's records on site at the facility at 9:00AM. LPA reviewed two staff personnel records on site at the facility at 10:20AM. LPA reviewed 4 children's psychotropic medications and medication records at 9:45AM. LPA interviewed one staff at 10:40AM. The other staff had to join a meeting for mental health certification while LPA was on site. Interview will be conducted at a later date. LPA interviewed one child currently taking psychotropic medication at 11:00AM. The other children were in school and will be interviewed at a later date. LPA conducted exit interview with Rita Johnson, Program Director at 11:30AM. LPA provided the summary report to Rita Johnson, Program Director upon completion. No deficiencies are being cited at this time.

met_with: Rita Johnson


summary: Facility Evaluation

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Narrative:
On September 22, 2022, Licensing Program Analysts (LPA's) Wayne Aoki and Briana Placencia conducted an unannounced annual inspection at Palo Alto Facility located in Fresno CA. LPA's met with Administrator Antolin Garza and facility house manager Mandy Perez. A physical plant inspection was completed and included the following checks. Adequate indoor and outdoor activity space and materials observed. The facility is maintained at 73 degrees. All facility smoke detectors are in appropriate working order, fire extinguisher is properly charged and serviced. Facility maintains an adequate supply of perishable and non-perishable foods. All required forms are posted. Medications are locked and centrally stored. Individual beds were observed. The facility is accredited through CARF with an inspection tentative for December 2022, they had a fire clearance completed on 1/31/2022 and they are approved through Fresno County Department of Behavioral Health through 2/23/2022. No firearms or weapons are allowed in the facility. There is no pool and no pets at the facility. LPAs reviewed 5 client files, and 10 staff files. LPAs interviewed 2 staff and no clients due to the clients all being in school. LPAs discussed the medication log, all required forms, intake process, needs and services plan, disaster preparedness plan and emergency intervention plan. LPAs requested the following updated documents by October 31, 2022. Lic 500, Lic 308, Lic 999, Lic 610c. Deficiencies are being cited on todays visit, see LIC809-D. A Civil Penalty was assessed for an employee not being associated to the facility. A copy of this report was left at the facility at the conclusion of todays inspection.

met_with: Antolin Garza


summary: Facility Evaluation

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Narrative:
On September 23, 2022, Licensing Program Analyst (LPA) Briana Placencia conducted an unannounced POC in person inspection at Fresno Youth Palo Alto and met with Antolin Garza. The purpose of the inspection was to clear POCs that were due today September 23, 2022. LPA cleared the following POCs: CCR 80088(b) Broken Window/Window Screen,the window has a temporary fix taped and window closed but due to window needing to be manufactured to exact size it will not be ready for 7-14 days, Licensee will send proof to LPA upon completion of window install. CCR 80087(c) Fire exits, the fire exit in the garage was free and clear to pass through, the emergency exit was also unlocked. CCR 80019(f) Criminal record clearance, licensee was able to enter into guardian and associate the staff as of 9/22/2022. ILS 87088(c)(4) Broken Drawers, licensee has purchased two new dressers in good condition for client bedroom #2. CCR 80087(a) holes in walls, licensee has patched up all holes, 2- living room,1- restroom, and 1-clients bedroom#3, licensee will send pictures via email once it has been painted. Final POC issued on 9/22/2022 has a deadline of 9/29/2022, the licensee plans to have the other POC completed by the deadline if not Licensee will contact LPA for an extension. There are no deficiencies to be cited on todays visit. A copy of this report was left at the facility at the conclusion of inspection.


summary: Facility Evaluation

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Narrative:
On January 24, 2023, Licensing Program Analyst (LPA) Wayne Aoki conducted an unannounced Annual/Random inspection at Fresno Youth Palo Alto Facility located in Fresno CA. LPA's met with Administrator Antolin Garza and facility house manager Mandy Perez. A physical plant inspection was completed and included the following checks. Adequate indoor and outdoor activity space and materials observed. The facility is maintained at 72 degrees. All facility smoke detectors are in appropriate working order, fire extinguisher is properly charged and serviced. Facility maintains an adequate supply of perishable and non-perishable foods. All required forms are posted. Medications are locked and centrally stored. Individual beds were observed. The facility is accredited through CARF on December 19, 2022, they had a fire clearance completed on 1/31/2022 and they are approved through Fresno County Department of Behavioral Health through 2/24/2023. No firearms or weapons are allowed in the facility. There is no pool and no pets at the facility. LPA reviewed 5 minor's files, and 5 staff files. LPAs interviewed 2 staff and 2 clients. LPA discussed the medication log, all required forms, intake process, needs and services plan, disaster preparedness plan and emergency intervention plan. LPAs requested the following updated documents by February 28, 2023. Lic 500, Lic 308, Lic 999, Lic 610c. There were no deficiencies sited during this inspection. A copy of this report was left at the facility at the conclusion of todays inspection.


summary: Facility Evaluation

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Narrative:
On June 21, 2024, Licensing Program Analyst (LPA) Miriam Flores travelled to Fresno Youth-Palo Alto House to conduct an Annual inspection. LPA met with House Manager, Mandy Perez. At 8: AM, an inspection of the physical plant was conducted. LPA observed adequate food supply, adequate bedding, storage space, activity space, hot water that measured 113.9 degrees F. At 10:30AM, staff interview was conducted. At 11:20PM, an inspection of staff record was completed. There are no clients placed at the facility. The facility will notify CCL once there is a formal approval for mental health and placement of their first client. CARF accreditation expires 12/31/25. Three technical advisories were provided on this date. The exit interview was conducted at 12:00PM and a copy of this report given to the House Manager. It is requested that the licensee submit the following updated forms to CCL: Emergency Intervention Plan and CARF certificate by 6/28/24 and Updated Program Statement by 8/21/24.


summary: Facility Evaluation

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Narrative:
On January 12, Licensing Program Analyst (LPA) Wayne Aoki was met by facility manager, Gustavo Ruiz. The purpose for this inspection is to conduct a Case Management regarding late incident reports that the facility has submitted to Community Care Licensing. The facility submitted incident reports on November 14, 2022 for the following dates incidents: (2) November 6, 2022 (2) November 4, October 31, October 30, October 28, The facility is cited for GENERAL LICENSING STANDARDS Title 22, Division 6, 80061(b) Reporting Requirements. A copy of this report along with Appeals Rights were left with the facility.

met_with: Gustavo Ruiz


facility_name: FRESNO YOUTH - WELDON HOUSE

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Investigation Findings:
13On Octuber 17, 2024, Licensing Program Analyst (LPA) Angelica Borja conducted a complaint inspection at Fresno Youth Weldon-House STRTP and met with Jordan Lett and Mandy Perez. The purpose of the inspection was to deliver the findings regarding the above complaint allegations. During the investigation, LPA conducted confidential interviews which revealed that in fact staff verbally abused the minors while in care and staff mishandled a minor while in care . Based on LPA's, interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Interim Licensing Standards are being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of the report and appeal rights were provided to the facility. SubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Angelica Borja 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 24-CR- STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont)CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FRESNO RO, E SHAW AVE FACILITY NAME: FRESNO YOUTH - WELDON HOUSEFACILITY NUMBER: 107204244

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

met_with: House Managesr, Jordan Lett and Mandy Perez


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Investigation Findings:
13Licensing Program Analysts (LPAs) Miriam Flores and Olivia Medrano conducted an unannounced visit to Fresno Youth Weldon in order to deliver the findings of the above allegations and met with Many Perez. Deeja Randles participated via phone. The Department has investigated the complaint alleging staff is not meeting the client's health needs and staff did not ensure the required amount of food is available for minors in care. LPAs conducted interviews and obtained documentation. There were inconsistencies in the confidential interviews. Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was left at the facility with appeal rights. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Miriam Flores LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


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Investigation Findings:
13Licensing Program Analysts (LPAs) Miriam Flores and Olivia Medrano conducted an unannounced visit to Fresno Youth Weldon House to deliver the findings of the above allegation and met with Lead House Manager, Mandy Perez. Interim Administrator, Deeja Randles participated of this unannounced via phone. The Department has investigated the complaint alleging staff did not keep youth's personal information confidential. LPA conducted interviews and obtained documentation. There were inconsistencies in the confidential interviews. Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted. A copy of this report was left at the facility with appeal rights. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Miriam Flores LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1


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Investigation Findings:
13On the above date, Licensing Program Analyst (LPA) Sonia Sanchez conducted a complaint inspection and met with Mandy Perez, House Lead and Daeja Randles, Intermin Administrator joined via phone. The purpose of the inspection was to deliver the findings for the above complaint allegations. The Department has investigated the complaint alleging Staff do not follow a licensed physician's medical orders, Staff mishandled a client's medications while in care, Staff provided medical advice to a client with out proper authorization, and Staff did not address a client's medical needs. LPA conducted interviews and obtained documentation. There were inconsistencies in the confidential interviews. Although the allegations may have happened or is valid, there is not a preponderance of evidence to provide the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was left at the facility with Mandy Perez, House Lead. UnsubstantiatedEstimated Days of Completion: SUPERVISORS NAME: Tamara Melikian LICENSING EVALUATOR NAME: Sonia Sanchez LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) - (06/04)Page: 1 of 1

met_with: Mandy Perez, House Lead


summary: Facility Evaluation

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Narrative:
Licensing Program Analyst (LPA) Priscilla Zamudio and Daiquiri Boyd traveled to Fresno Youth-Weldon House House to conduct an Annual Inspection. LPAs met with Jordan Lett, House Manager . The home is one story, three bedrooms and two bathrooms. An inspection of the facility was completed and the following was observed: Hot water temperature measured within appropriate range, All smoke detectors were in proper working order, Menu was posted, First aid kit available, Medications were centrally stored and locked, Fire extinguishers properly charged, adequate indoor and outdoor activity space and activities observed. Clients appeared to have adequate clothing and storage space, adequate supply of linens observed, sharps locked. Facility does not have any bodies of water. Per the House Manager, there are no weapons at the facility. Client files were reviewed for compliance on this date. LPAs conducted exit interview with Jordan and provided a copy of this report. LPA's Zamudio and Boyd were unable to complete interviews and staff file review due to conflicts and obtained staff signature from Daeja Randles, Case Manager

met_with: Jordan Lett, House Manager


summary: Facility Evaluation

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Narrative:
Licensing Program Analysts (LPA) Priscilla Zamudio and Daiquiri Boyd completed a visit to the corporate office to review staff records and met with Daeja Randles, Case Manager. Facility has no active waivers or exceptions. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index check clearances or exemptions.


summary: Facility Evaluation

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Narrative:
Licensing Program Analysts (LPA) Priscilla Zamudio and Daiquiri Boyd traveled to the facility to complete staff and client interviews, however, due to time constraints and clients not available for interview, LPAs were only able to complete interview with staff Jordan Lett, House Manager. One client present was unable to interview. A copy of this 809 was emailed to facility, due to technical difficulties.


summary: Facility Evaluation

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Narrative:
On March 2, Licensing Program Analyst (LPA) Wayne Aoki conducted an unannounced Annual/Random inspection at Fresno Youth Weldon Facility located in Fresno CA. LPA's met with House Manager, Jordan Lett. A physical plant inspection was completed and included the following checks. Adequate indoor and outdoor activity space and materials observed. The facility is maintained at 73 degrees. All facility smoke detectors are in appropriate working order, fire extinguisher is properly charged and serviced. Facility maintains an adequate supply of perishable and non-perishable foods. All required forms are posted. Medications are locked and centrally stored. Individual beds were observed. The facility is accredited through CARF on December 19, 2022, they had a fire clearance completed on 2/01/2022 and they are approved through Fresno County Department of Behavioral Health through 2/20/2024. No firearms or weapons are allowed in the facility. There is no pool and no pets at the facility. LPA reviewed 3 minor's files, and 5 staff files. LPAs interviewed 2 staff and 1 client. LPA discussed the medication log, all required forms, intake process, needs and services plan, disaster preparedness plan and emergency intervention plan. LPAs requested the following updated documents by , April 1, 2023. Lic 500, Lic 308, Lic 999, Lic 610c. There were no deficiencies sited during this inspection. A copy of this report was left at the facility at the conclusion of todays inspection.

met_with: Jordan Lett


summary: Facility Evaluation

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Narrative:
An unannounced Psychotropic Medication Inspection was conducted by Licensing Program Analyst (LPA) Tamara Melikian on April 3, 2023 at 9:00AM. This case management inspection is conducted pursuant to Health and Safety Code 1538.9(a)(2). During the inspection, LPA met with Antolin Garza, Administrator and inspected the facility inside and out. LPAs reviewed 1 child's records and 2 staff personnel files on site at the facility. LPAs reviewed 1 child's psychotropic medications and medication records. LPAs interviewed 2 staff on site to discuss the facilities policies and procedures of operation. LPAs interviewed one child on site currently on psychotropic medication. LPAs provided a copy of the licensing report to Administrator, Antolin Garza. No deficiencies are being cited at this time. LPA conducted exit interview with Antolin Garza, Administrator.


summary: Facility Evaluation

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Narrative:
On June 19, Licensing Program Analyst (LPA) Miriam Flores conducted an unannounced visit to Fresno Youth - Weldon House in Fresno, CA for the purpose to follow up on an incident report dated 5/15/24. LPA met with House Manager, Jordan Lett. House Manager, Jordan Lett was able to provide copies of the quarterly reports and needs and services plan for C1. Copy of the medication training log will be emailed by 6/19/24. No deficiencies were observed or cited. An exit interview was conducted and a copy of this report was provided to the House Manager.


summary: Facility Evaluation

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Narrative:
Licensing Program Analysts (LPAs) Miriam Flores and Olivia Medrano conducted an unannounced visit to Fresno Youth Weldon to follow up on a complaint Plan Of Correction and met with Mandy. Deeja Randles participated via phone. The Department investigated a complaint dated 7/26/24 and Licensee submitted a plan of correction of S1 which was cleared by the Department on 10/18/24. Subsequently, the licensee requested to submit a new plan of correction to the Department reflecting the licensee's termination of employment for S1 (see LIC811 dated 01/06/2025). The department amended the POC on this date without additional citations being issued. An exit interview was conducted and copy of this report was left at the facility.


summary: Facility Evaluation

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Narrative:
On January 17, Licensing Program Analysts (LPAs) Miriam Flores and Sonia Sanchez traveled to Fresno Youth Weldon House to conduct a case management inspection and met with Assistant Manager, Jordan Lett. The purpose of the inspection was to discuss incident report sent to Community Care Licensing (CCL) dated 01/06/2025, regarding medication error for C1 (see LIC811- Ref #1). There was no medical care needed for C1 and S1 received medication training. LPAs determined this to not be an immediate risk to health and safety at this time. No deficiencies are being cited. LPAs conducted an exit interview and a copy of this report was left with Assistant Manager, Jordan Lett.


summary: Facility Evaluation

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Narrative:
On March 20, Licensing Program Analyst (LPA) Miriam Flores traveled to Fresno Youth Weldon House to conduct a case management inspection and met with Interim Administrator, Deaja Randles. The purpose of the inspection was to discuss incident reports that were sent to Community Care Licensing (CCL) dated 03/04/25,03/05/25, and 03/06/25 (2x), for C1 (see LIC811- Ref #1) refusing to take psychotropic medication. LPA completed a file review and collected copies of supportive documentation. LPA determined this is not an immediate risk to health and safety at this time. No deficiencies are being cited. LPA conducted an exit interview and a copy of this report was left with Interim Administrator, Deaja Randles..

met_with: Deaja Randles


summary: Facility Evaluation

raw_content:
Narrative:
On April 14, Licensing Program Analysts (LPAs) Miriam Flores and Angelica Borja travelled to Fresno Youth-Weldon House to conduct an Annual/Random inspection. LPAs met with Interim Administrator, Daeja Randles. At 9:20AM, LPAs reviewed client's files. At 11:00AM, LPAs reviewed staff files and emergency intervention plan. At 12:00PM, LPAs conducted an inspection of the physical plant. LPAs observed adequate food supply, adequate bedding, storage space, activity space, hot water that measured 122.1 degrees F. Room temperature measured 69 degrees. At 1:00PM, LPAs completed interviews with staff and youth in placement. Youth in placement were present at the facility. Mental Health Program Approval expires on February 24, 2026. CARF accreditation expires 12/31/25. Two technical advisories and one technical violation were provided on this date. The exit interview was conducted at 1:30PM and a copy of this report and appeal rights were given were provided to Interim Administrator.

met_with: Daeja Randles